TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 


THE  MACMILLAN  COMPANY 

NEW  YORK  •   BOSTON  •   CHICAGO   •  DALLAS 
ATLANTA    •    SAN   FRANCISCO 

MACMILLAN  &  CO.,  LIMITED 

LONDON   •  BOMBAY   •  CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OF  CANADA,  LTD. 

TORONTO 


7183 


TUBERCULOSIS 


OF  THE 


LYMPHATIC  SYSTEM 


BY 

WALTER  BRADFORD  METCALF,  M.D. 

ASSOCIATE  IN  CLINICAL  MEDICINE,  UNIVERSITY  OF  ILLINOIS,  COLLEGE 

OF  MEDICINE.    MEMBER,  CONSULTING  STAFF  COOK  COUNTY  HOSPITAL, 

CHICAGO  MUNICIPAL  TUBERCULOSIS  SANITARIUM,  LAKE  GENEVA 

SANITARIUM,  VOLUNTEER  MEDICAL  SERVICE  CORPS  OF  THE 

UNITED  STATES:  FO^M^RLY,  \TTENDING  PHYSICIAN  COOK 

COUNTY  HOSEITAJ-.,  DE  ^ARTME^Tr1  OF  TUBERCULOSIS 


lark 

THE  MACMILLAN  COMPANY 
1919 

All  rights  reserved 


COPYRIGHT,  xgig 

BY  THE  MACMILLAN  COMPANY 
Set  up  and  printed.    Published  March,  IQIQ. 


Lbraiy 


tn 

PREFACE 

The  following  pages  represent  an  attempt  to  emphasize  the 
importance  of  glandular  tuberculosis,  especially  as  it  occurs 
during  childhood.  Up  to  recent  times  there  has  been  a  tendency 
to  consider  this  condition  only  as  a  local  affair,  but  the  modern 
view  of  considering  the  majority  of  cases  of  adult  tuberculosis 
as  autoinfections  from  old  foci,  contracted  during  childhood, 
places  the  question  of  glandular  tuberculosis  in  another  light. 
"Hilus  tuberculosis"  is  an  established  entity.  Tuberculous 
bronchial  glands,  the  result  of  a  childhood  infection,  undoubtedly 
are  the  most  common  source  of  adult  pulmonary  tuberculosis. 
The  profession  is  just  awakening  to  the  fact  that  pulmonary 
tuberculosis  of  the  adult  can  be  prevented  by  proper  prophylactic 
methods  during  childhood. 

No  condition  so  influences  the  development  of  the  thorax  as 
a  tuberculous  infection  of  the  bronchial  glands.  In  fact,  the 
entire  development  of  the  child  is  markedly  influenced  by  such 
infection.  There  is  increasing  evidence  that  the  so-called  delicate 
and  frail  child  is  delicate  and  frail  because  of  an  existing  tuber- 
culous tracheo-bronchial  adenopothy. 

The  surgeon  is  slowly  giving  up  the  field  of  tuberculous  cervical 
adenitis.  This  condition  should  never  be  allowed  to  become  a 
surgical  question.  Tuberculosis  of  the  lymphatic  system,  espe- 
cially during  childhood,  should  be  considered  a  serious  affliction 
and  be  worthy  of  our  best  efforts,  and  if  proper  medical  treat- 
ment is  instituted  during  this  primary  stage  of  the  infection 
nearly  all  cases  will  respond  favorably—  limit  the  course  of  the 
disease,  and  reduce  its  mortality. 

A  comparatively  large  space  has  been  given  to  the  subject 

of  anatomy  of  the  lymphatic  system,  the  importance  of  which 

is  seen  when  we  begin  to  study  the  portals  of  entry  of  the  infec- 

tion, and  the  subsequent  spreading  of  the  disease. 

In  the  treatment  of  tuberculosis  the  importance  of  fresh  air, 


624023 


vi  PREFACE 

good  food  and  hygienic  surroundings  is  conceded  by  everyone. 
But  the  one  agent,  which  in  the  author's  opinion  is  the  foremost 
weapon  in  our  fight  against  tuberculosis,  namely  tuberculin,  has 
been  sadly  neglected  in  our  country. 

In  these  pages  a  plea  is  made  for  the  rational  use  of  tuberculin 
as  a  diagnostic  and  therapeutic  agent  with  special  reference  to 
its  value  in  tuberculosis  of  the  lymphatic  system. 

The  author  wishes  to  graciously  express  his  appreciation  for 
the  able  assistance  rendered  him  by  Assistant  Surgeon  Edwin 
Peterson,  U.  S.  N.  R.  F.  The  many  valuable  references  from 
French,  German  and  Swedish  medical  literature  were  translated 
by  him.  He  is  also  indebted  to  Dr.  Roy  M.  Bowell  for  the  com- 
pilation of  parts  of  the  subject-matter. 

WALTER  BRADFORD  METCALF,  M.D. 
October,  1918 


CONTENTS 

CHAPTER                                                                                    PAGE 
I.  GENERAL  ANATOMICAL  CONSIDERATIONS i 

The  development  of  the  lymphatic  system.    The  lym- 
phatic vessels.    The  lymphatic  glands. 

II.  ANATOMICAL  RESUME  or  THE  MOST  IMPORTANT  GLANDULAR 
CHAINS  AND  AREAS  OF  LYMPHATIC  DRAINAGE  OF 
HEAD  AND  NECK 6 

LYMPHATIC  GLANDS  OF  HEAD  AND  NECK 6 

Occipital,  auricular,  parotid,  superficial  cervical, 
submaxillary,  submental,  retropharyngeal,  deep 
cervical,  prelaryngeal,  and  pretracheal  glands. 

AREAS  OF  LYMPHATIC  DRAINAGE  OF  HEAD  AND  NECK     10 
Skin,  eye,  ear,  nasal  cavity,  accessory  sinuses, 
gums,  teeth,  oral  cavity,  throat  and  larynx. 

TONSILLAR  RING  OF  WALDEYER 12 

The  palatine  tonsil,  the  lingual  tonsil  and  the 
pharyngeal  tonsil. 

VISCERAL  LYMPHATIC  GLANDS  OF  THE  THORAX 14 

Mediastinal  and  bronchial  glands. 

LYMPHATIC  GLANDS  OF  THE  ABDOMEN 16 

Mesenteric,  mesocolic,  caecal,  appendicular,  gas- 
tric, hepatic,  pancreatic,  pancreatico-splenic, 
cceliac  and  lumbar. 

LYMPHATIC  GLANDS  OF  THE  PELVIS 18 

Ano-rectal,  para-uterine,  vesicular,  hemorrhoidal, 
sacral,  hypogastric  and  iliac. 

LYMPHATIC  GLANDS  OF  THE  UPPER  EXTREMITIES  ....     19 
Antibrachial,  supra-trochlear,  deep  cubital  and 
axillary. 

LYMPHATIC  GLANDS  OF  THE  LOWER  EXTREMITIES  ....     20 
Anterior  tibial,  popliteal,  posterior  tibial  and  in- 
guinal. 
III.  PHYSIOLOGICAL  CONSIDERATIONS 21 

Composition  of  lymph,  circulation  of  lymph,  formation 

of  lymph,  function  of  the  lymphatic  vessels  and  the 

lymph-glands. 


viii  CONTENTS 

CHAPTER  PAGE 

IV.  ETIOLOGY 25 

HISTORY 25 

BACTERIOLOGY 25 

Bacillus  tuberculosis  humanus: 

Morphology,   staining  characteristics,  culture 

characteristics,  resistance,  chemistry. 
Varieties  of  tubercle  bacilli: 

Bacillus  tuberculosis  bovis. 

Bacillus  tuberculosis  avium. 

Bacillus  tuberculosis  piscium. 

Saprophytic  acid  proof  bacilli. 
Phylogenesis  and  change  of  type: 

Phylogenesis,  relation  between  human  and 

bovine  types,  change  of  type. 
Incidence  of  infection  and  its  source: 

Human  and  bovine  types. 

OTHER  FACTORS  HAVING  BEARING  ON  THE  ETIOLOGY.    36 
Predisposition — general  and  hereditary. 
Previous  diseases: 

Acute  infections. 

Instability  of  nervous  system. 

Digestive  disturbances. 

Infections  of  upper  air  passages. 

Dental  defects. 
Environments: 

Climate,  topography,  social  conditions,  home, 

school,  factory. 
Frequency, 

Age  and  site. 
Relation  between  scrofulosis  and  tuberculosis: 

Cornet's  views,  Virchow's  views,  Escherich's 

theory,    Czerny's    theory,    Heubner's    views, 

Salge's  views,  Hochsinger's  views,  Saltman's 

views,  Eustace  Smith's  views,  American  ideas. 

V.  PATHOLOGY 58 

PATHOGENESIS 58 

MODES  OF  INFECTION 60 

Congenital  transmission,  bronchogenous  infec- 
tion. 


CONTENTS  ix 

CHAPTER  PAGE 

Enterogenous  infection. 
Infection  of  the  external  lymph-glands. 
Cervical  glands. 
Portals  of  entry: 

Palatine     tonsils,     pharyngeal     tonsil, 
mucous  membrane  of  nose,  mouth  and 
pharynx,  teeth,  eye,  ear,  skin  and  scalp. 
Prelaryngeal  glands. 
Axillary  glands. 
Inguinal  glands. 

Role  of  the  lymph-glands  in  tuberculous  infec- 
tion of  childhood. 

MORBID  ANATOMY 79 

Formation  of  the  tubercle. 
Glandular  involvements. 
Bronchial  glands,  cervical  glands. 
Mesenteric  glands. 
Other  glands. 
Tuberculous  lymphangitis. 
Anyloid  degeneration. 

VI.  SIGNS  AND  SYMPTOMS 85 

BRONCHIAL  GLANDS 86 

General  symptoms: 

Physical  signs — Inspection,  palpation,  percus- 
sion and  auscultation. 
Course  and  complications. 

CERVICAL  GLANDS 95 

Development,  suppuration,  sinuses, 
Secondary  infection,  progress, 
Tonsils. 

MESENTERIC  GLANDS 98 

Usually  a  secondary  infection,  general  symptoms, 
local  manifestations. 

OTHER  LYMPHATIC  GLANDS 101 

Frequency. 

Axillary,  cubital,  inguinal,  popliteal. 

GENERALIZED  TUBERCULOUS  ADENITIS 103 

TUBERCULOUS  LYMPHANGITIS 103 


x  CONTENTS 

CHAPTER  PAGE 

VII.  PROGNOSIS 105 

General  remarks,  tuberculosis  of  bronchial,  mesenteric, 
and  cervical  lymphatic  glands. 

VIII.  DIAGNOSIS 109 

CLINICAL  DIAGNOSIS 109 

Tuberculosis  of  the  bronchial  glands. 

History,  insidious  onset,  general  symptoms. 
Physical  findings,  X-ray. 
Tuberculosis  of  the  cervical  glands. 
Direct  diagnosis. 

Differential,    Syphilis,   Lymphatic   Leukemia, 
Hodgkin's  Disease,  Cysts,  Malignancy, 
Actinomycosis. 
Tuberculosis  of  the  mesenteric  glands. 

Direct  and  differential. 
Tuberculosis  of  other  lymphatic  glands. 
Axillary,  cubital,  inguinal,  popliteal. 

SPECIFIC  DIAGNOSTIC  METHODS 118 

Tuberculin  diagnosis. 
v.  Pirquet's  test. 
Moro's  ointment  test. 
Intracutaneous  test. 
Subcutaneous  test. 
Complement  fixation  test. 
Agglutination  test. 

IX.  TREATMENT 145 

PROPHYLAXIS 145 

GENERAL  TREATMENT 151 

SPECIFIC  TREATMENT 153 

With  a  few  theoretical  considerations  on  Tuber- 
culin and  immunity. 
History  of  Tuberculin,  varieties,  action. 
Immunity,  theories  of  action,  general  and  local 

action: 

Indications  and  contraindications. 
Method  of  administration: 
Reactionless  treatment,  toxic  phenomena. 
Site  of  and  tune  for  injection. 
Actual  dosage,  duration  of  treatment. 


CONTENTS  xi 

CHAPTER  PAGE 

Results. 
Dilution  of  Tuberculin  and  preparation  of  doses. 

X-RAY  THERAPY 174 

Biological  effects,  selective  action,  healing  action, 
technique,  dosage,  dangers,  views  of  investiga- 
tors. 

SURGICAL  TREATMENT 182 

Radical  operation  of  tuberculous  cervical  adenitis 

Technique,  disadvantages,  results. 
Curettement. 
Aspiration  and  incision. 

HELIOTHERAPY 191 

Rollier's  method: 
Action  and  effect,  results,  disadvantages. 

OCEAN  CLIMATE.    MOUNTAIN  CLIMATE 195 

SOAP  TREATMENT 196 


TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 


Axillary 
glands 


Anterior  tibial 
glands 


PLATE  I.— SUPERFICIAL  LYMPH-VESSELS.  All  superficial  lymph- 
vessels  are  in  black;  the  deep  lymph-vessels  throughout  are  colored  red; 
afferent  vessels  are  represented  by  continuous  lines,  and  efferent  vessels, 
by  dotted  lines. 


TUBERCULOSIS 

OF  THE  LYMPHATIC  SYSTEM 

CHAPTER  I 
GENERAL  ANATOMICAL  CONSIDERATIONS 

The  Lymphatic  System. — The  development  of  the  lymphatic 
system  has  not  been  very  well  understood  until  recent  years. 
The  close  resemblance  between  the  lymphatic  vessels  and  the 
veins  has  always  been  noted,  but  it  was  not  until  the  last  dec- 
ade that  the  true  relationship  between  the  two  systems  was 
established.  Modern  researches,  have  proven  conclusively  that 
the  lymphatic  system  is  a  4jverticuhim  from  the  veins  and  grows 
into  the  organs  by  a  process  of  budding.1  The  lymphatics  hence 
constitute  a  closed  system  which  is  lined  throughout  with  en- 
dothelium.  It  resembles  the  bloodvascular  system  in  many 
points,  but  differs  markedly  in  others.  Like  the  latter,  it  is 
made  up  of  capillaries  and  larger  vessels,  but  their  contents 
always  flow  in  a  centripetal  direction,  as  is  shown  by  the  posi- 
tion of  numerous  valves  and  the  gradual  increase  in  size  of  the 
vessels  as  they  travel  toward  the  neck,  eventually  emptying  in 
the  larger  veins  of  this  region.  (See  Figure  i,  Plate  III.) 
Another  important  difference  is  the  presence  of  glands  in  the 
course  of  the  lymphatic  vessels. 

The  Lymphatic  Capillaries  constitute  blind  sacs  which  dip 
into  the  tissue  spaces  but  are  not  continuous  with  them.  They 
anastomose  freely  with  each  other,  the  lymph  travelling  in  the 
direction  of  the  least  resistance.  The  lymphatic  capillaries  are, 
as  a  rule,  larger  than  the  blood  capillaries;  their  calibre  varies 
greatly  within  short  distances.  The  capillaries  are  lined  by  a 
single  layer  of  nucleated  endothelial  cells  with  characteristic 
crenated  margins.  By  the  union  of  the  capillaries  larger  channels 
are  formed. 


2         TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

The  Lymphatic  Vessels  Proper. — The  close  relationship  be- 
tween these  vessels  and  the  veins  is  clearly  seen.  In  structure 
they  resemble  each  other  markedly.  The  endothelial  linings 
are  of  the  same  character,  but  the  muscular  tissue  in  the  wall  of 
the  lymphatic  vessel  is  less  in  quantity.  Numerous  valves  are 
present  along  the  course  of  the  vessels  thus  rendering  backward 
flow  of  the  lymph  nearly  impossible.  The  vessel  is  somewhat 
dilated  above  each  valve,  giving  it  a  beaded  appearance.  The 
lymphatic  vessels  collect  the  lymph  from  the  different  regions 
of  the  body,  carry  it  through  the  lymph-glands,  and  after  leaving 
the  gland  converge  and  form  the  terminal  lymphatic  trunks. 

The  Terminal  Lymphatic  Trunks. — The  Jugular  Trunk  takes 
care  of  the  lymph  of  the  corresponding  side  of  the  head  and  neck 
and  is  formed  by  the  union  of  the  efferent  vessels  of  the  inferior 
deep  cervical  glands. 

The  Subclavian  Trunk  takes  care  of  the  lymph  of  the  upper 
extremity  of  the  corresponding  side,  draining  the  axillary  glands. 

The  Broncho-mediastinal  Trunk  drains  the  lymph  from  the 
visceral  lymphatic  of  the  thorax  and  of  the  internal  mammary 
chain. 

The  Right  Lymphatic  Duct. — The  Termination  of  these  trunks 
varies  on  the  two  sides.  On  the  right  side  the  three  trunks  may 
empty  separately  into  the  junction  of  the  subclavian  and  inter- 
nal jugular  veins.  The  three  vessels  may  converge  and  form 
the  right  lymphatic  duct. 

This  Duct  is  more  commonly  formed  by  the  union  of  the 
right  subclavian  and  jugular,  the  broncho-mediastinal  emptying 
separately.  The  right  duct  drains  the  right  side  of  the  head  and 
neck,  the  right  upper  extremity,  right  side  of  thorax,  right  lung, 
right  heart  and  convex  surface  of  the  liver. 

On  the  left  side  the  three  trunks  may  empty  into  the  thoracic 
duct,  although  this  rarely  occurs;  the  subclavian  and  broncho- 
mediastinal  trunks  usually  converge  or  empty  separately  into 
the  venous  junction.  The  termination  of  each  trunk  is  guarded 
by  valves. 

The  Thoracic  Duct  conveys  the  mass  of  lymph  from  the 
greater  part  of  the  body  into  the  blood;  it  is  formed  by  the  union 


/Thoracic  duct 


Mediastinal 
glands 
and  vessels 


Intercostal 

glands 
ond  vessels 


Sacral 
glands 


Receptaculum 
chyli 


Lumbar 
lymphatics 


Common 

ntestinal 

trunk 


External 

Iliac 
glands 


PLATE  II. — A  schematic  presentation  of  the  lymphatics  of  the  thorax  into  the  thoracic 
duct,  and  the  abdominal  lymphatics  into  the  receptaculum  chyli. 


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511 


of  the  right  and  left  lumbar  trunks  draining  the  retro-peritoneal 
organs,  thus  taking  care  of  the  lymph  from  the  lower  extremities, 
deep  portions  of  the  abdominal  and  pelvic  walls.  The  intestinal 
trunk  may  enter  at  the  same  point  draining  the  intra-peritoneal 
organs,  thus  pouring  in  the  chyle  from  the  small  intestines. 

The  Triangular  Dilatation,  the  receptaculum  chyli,  presents 
itself  a  little  above  the  origin  of  the  thoracic  duct,  thus  being  on 
a  slightly  higher  level  than  the  umbilicus,  opposite  to  the  first 
and  second  lumbar  vertebrae. 

The  Thoracic  Duct  enters  the  thorax  through  the  aortic  open- 
ing of  the  diaphragm,  lying  to  the  right  of  the  aorta.  Opposite 
the  fourth  thoracic  vertebra  it  inclines  toward  the  left  and 
ascends  behind  the  arch  of  aorta  and  on  the  left  side  of  the 
oesophagus  to  the  upper  orifice  of  the  thorax;  opposite  the 
seventh  cervical  vertebra  it  turns  outward  between  the  vertebral 
and  common  carotid  arteries  and  then  downward  over  the  sub- 
clavian  artery  to  terminate  in  the  left  subclavian  vein  at  the 
angle  of  junction  with  the  left  internal  jugular  vein. 

The  Duct  averages  about  45  c.  m.  in  length  and  is  provided 
with  several  valves,  the  most  perfect  being  situated  near  its 
termination  to  prevent  the  regurgitation  of  the  blood. 

The  Thoracic  Duct  drains  the  body  below  the  diaphragm 
and  the  left  side  of  the  body  above  the  diaphragm.  It  does  not 
drain  the  convex  surface  of  the  liver. 

The  Lymphoid  Tissue  consists  of  reticular  connective  tissue 
and  a  special  type  of  cells,  the  lymphoid  cells  which  fill  in  the 
meshes  of  the  reticulum.  Lymphoid  tissue  may  be  diffuse  or 
circumscribed.  The  diffuse  type  is  found  in  the  mucous  mem- 
branes of  the  respiratory  passages,  throughout  the  intestinal 
tract,  in  the  bone-marrow,  etc.  The  circumscribed  type  may 
occur  as  solitary  follicles  in  the  intestinal  mucosa  or  aggregated 
follicles  (Peyers  patches),  especially  in  the  lower  end  of  the 
ileum. 

The  more  complex  structure  of  lymphoid  tissue  constitutes 
the  lymphatic  glands. 

Lymphatic  Glands  are  numerous  and  widely  distributed 
bodies,  which  lie  along  the  course  of  the  lymphatic  vessels.  The 


4         TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

number  varies  greatly  in  different  individuals.  They  often  occur 
in  groups  of  from  three  to  six,  even  ten  to  fifteen,  forming  chains 
which  are  placed  in  direct  relation  to  the  region  which  their 
afferent  vessels  drain. 

The  glands  are  usually  rounded  in  form  but  may  be  elon- 
gated or  cylindrical.  In  shape  they  somewhat  resemble  a  bean, 
due  to  a  concavity  called  the  hilum,  where  the  connective  tissue 
of  the  capsule  extends  deeply  into  the  substance  of  the  node. 
This  depression  serves  as  point  of  entrance  for  the  main  arteries 
and  nerves  and  of  exit  for  the  veins  and  efferent  lymph- vessels. 
The  afferent  lymph- vessels  enter  on  the  convex  side. 

The  glands  are  firm  and  elastic  in  consistency.  They  vary 
in  size  from  the  invisible  to  the  size  of  an  olive.  Their  color 
depends  upon  the  location.  They  are,  as  a  rule,  whitish.  The 
tracheo-bronchial  glands  are  dark  colored,  due  to  the  infiltration 
of  small  particles  of  coal,  those  of  the  liver  yellow,  etc.  The 
glands  are,  as  a  rule,  embedded  in  adipose  connective  tissue,  in 
which  they  are  easily  movable. 

On  Miscroscopical  Examination,  the  gland  is  shown  to  be 
surrounded  by  a  distinct  capsule,  which  externally  is  continuous 
with  the  cellule-adipose  tissue.  The  inner  capsular  layer  sends 
prolongations  into  the  gland  substance  from  the  hilum,  forming 
the  so-called  trabeculae.  (See  Figure  2,  Plate  III.) 

The  gland  substance  proper  is  separated  from  the  capsule  by 
the  peripheral  lymphatic  sinus. 

The  outer  portion  of  the  gland,  the  cortex,  is  composed  of 
regularly  arranged  lymph-nodules,  trabeculae  and  sinuses  thus 
distinguishing  it  from  the  medulla.  The  center  of  each  nodule 
is  the  seat  of  active  proliferation  of  the  lymphoid  cells,  thus 
forming  the  Germinal  Center. 

The  central  portion  of  the  gland,  the  medulla,  is  made  up  of 
strands  of  lymphoid  tissue,  the  lymph-cords,  which  extend  from 
the  nodules  of  the  cortex  forming  an  irregular  mass  of  tissue. 
Hence  the  difference  between  the  cortex  and  medulla  is  only 
one  of  degree. 

The  reticular  network  forms  part  of  the  lymphatic  tissue 
proper  and  is  continuous  with  the  connective  tissue  of  the  tra- 


GENERAL  ANATOMICAL  CONSIDERATIONS  5 

beculae  and  capsule.  The  reticulum  serves  as  a  meshwork  for 
the  lymphoid  cells  which  nearly  obscure  it  in  the  nodules. 

The  Afferent  Lymphatics,  entering  the  gland  on  its  convex 
surface,  form  a  plexus  of  capillaries,  which  by  their  anastomoses 
produce  the  peripheral  sinus.  From  this  sinus  internodular 
branches  run  towards  the  medulla,  anastomosing  freely  with 
each  other  throughout  the  glandular  substance.  Thus  the 
lymphoid  tissue  is  bathed  on  nearly  every  side  with  lymph.  In 
the  hilum  of  the  gland  the  sinuses  collect  into  the  terminal  sinus, 
which  communicates  with  the  efferent  lymphatics,  leaving  at. 
the  hilum.  (See  Figure  3,  Plate  III.) 

The  Blood  Supply.— The  gland  receives  blood  supply  from  two 
sources,  through  the  hilum  and  through  the  convex  surface  of 
the  capsule.  The  arteries  entering  through  the  hilum  are  the 
larger  and  ramify  along  the  trabeculae,  giving  off  numerous 
branches,  finally  being  resolved  into  a  very  rich  capillary  net- 
work, which  extends  into  the  cortical  lymph-nodules  and  the 
medullary  lymph-cords. 

The  vessels  entering  through  the  convex  surface  of  the  gland 
supply  the  capsule  and  trabeculae  anastomosing  in  some  cases 
with  the  other  group. 

The  nerve  supply  consists  of  both  non-medullated  and  medul- 
lated  fibers;  their  exact  significance  is  uncertain — some  of  them 
are  without  question  vasomotor  in  character. 


CHAPTER  II 

ANATOMICAL  RESUME  OF  THE  MOST  IMPORTANT 
GLANDULAR  CHAINS  AND  AREAS  OF  LYMPHATIC 
DRAINAGE  OF  HEAD  AND  NECK 

The  profound  studies  of  the  lymphatic  system,  made  many 
years  ago  by  SAPPEY,  stand  the  test  of  modern  investigations. 
DELAMERE,  POIRTER  and  CuNEO,2  basing  their  work  upon  that 
of  SAPPEY,  have  added  many  facts  to  our  knowledge  of  the  lym- 
phatic apparatus. 

In  more  recent  years  BEITZKE,  Mosx,3  P.  BARTELS,*  W.  S. 
MiLLER,8'9  G.  SCHWEITZER  and  others,  have  made  extensive 
researches  with  respect  to  the  lymph-passages.  The  following 
facts  are  mainly  drawn  from  the  works  of  these  modern  investi- 
gators. 

LYMPHATIC  GLANDS  OF  HEAD  AND  NECK 

The  Occipital  Glands  are  two  to  three  in  number  on  each  side 
of  the  median  line,  between  the  anterior  border  of  the  Trapezius 
and  insertion  of  the  Complexus.  They  drain  the  occipital  region 
of  the  scalp  and  send  their  efferent  vessels  down  to  the  deep 
cervical  glands. 

The  Auricular  Glands  may  be  divided  into  the  three  following 
groups: 

The  Pre-auricular  Glands  are,  as  a  rule,  one  to  two  in  number 
and  are  located  just  in  front  of  the  tragus.  They  drain  the  an- 
terior and  upper  part  of  the  external  ear  and  the  anterior  temporal 
region  of  the  scalp;  their  efferent  vessels  go  to  the  parotid  glands. 

The  Infra-auricular  Glands  are  located  just  beneath  the  ear 
and  are  one  to  two  in  number;  they  drain  the  inferior  part  of  the 
external  ear  and  send  their  efferent  vessels  to  the  parotid  glands. 

The  Retro-auricular  Glands,  also  called  the  Mastoid  Glands, 
are  situated  just  beneath  the  border  of  the  Retrahens  aurem 


Auricular 
glands 


Parotid 
salivary  g.' 

Occipital 
glands 


Superior 
dee?  cervical 
glands 


Superficial  parotid 
lymphatic  glands 


ubmaxillary 
glands 


Submental 
glands 


Omo-hyoid 

muscle 


PLAE  IV.— A  schematic  drawing  showing  the  drainage  from  the  superficial  lymphatics  of 
the  head  to  the  deep  lymphatics  in  the  neck,  in  accordance  with  descriptions. 


ANATOMICAL  RESUME  7 

muscle.  They  drain  the  posterior  surface  of  the  external  ear 
and  the  adjacent  region  of  the  scalp  and  send  their  efferent 
vessels  down  to  the  deep  cervical  glands. 

The  Parotid  Lymph-glands  may  be  divided  into  two  groups 
with  reference  to  their  relation  to  the  parotid  salivary  gland. 

The  Superficial  Parotid  Glands  are  situated  just  beneath  the 
fascia,  partially  embedded  in  the  superficial  layers  of  the  salivary 
gland;  their  afferent  vessels  arise  from  the  anterior  surface  of 
the  external  ear,  root  of  the  nose,  forehead,  eyelids,  upper  part 
of  the  cheek,  anterior  temporal  portion  of  the  scalp  and  from 
some  of  the  auricular  glands.  The  efferent  vessels  pass  mainly 
to  the  deep  and  superficial  cervical  glands. 

The  Deep  Parotid  Glands  are  situated  in  the  substance  of 
the  salivary  gland  and  are  usually  two  to  four  in  number.  They 
drain  the  ocular  conjunctiva,  deep  portion  of  the  forehead,  root 
of  the  nose  and  temporal  region  of  the  scalp  and  the  substance 
of  the  parotid  salivary  gland.  The  efferent  vessels  pass  into  the 
superficial  and  deep  cervical  glands. 

The  Superficial  Cervical  Lymph-glands  are  three  to  four  in 
number  and  lie  beneath  the  superficial  cervical  fascia  on  the 
Sterno-cleido-mastoid  muscle,  near  the  angle  of  the  jaw  in  the 
region  of  the  external  jugular  vein.  They  drain  the  parotid 
region  of  the  face  and  the  external  ear.  They  also  receive  the 
lymph  from  the  submaxillary,  parotid  and  auricular  glands;  the 
efferent  vessels  go  to  the  deep  cervical  glands. 

The  Submaxillary  Lymph-glands  are  located  in  the  sub- 
maxillary  triangle  along  the  anterior  border  of  the  mandible, 
resting  on  the  submaxillary  salivary  gland.  Their  number 
and  position  are,  according  to  MOST,  very  constant.  They  con- 
sist of  three  glands  or  gland  groups  which  BARTELS  has  named 
the  anterior,  middle  and  posterior. 

The  Anterior  Gland  lies  in  the  anterior  angle  of  the  submaxil- 
lary triangle  on  the  Mylohyoid  muscle  near  the  anterior  belly 
of  the  Digastric  muscle  on  the  submental  vein. 

The  Mesial  Gland  is,  as  a  rule,  the  largest  and  is  located  along 
the  border  of  the  lower  jaw  just  mesially  to  the  external  maxil- 
lary artery. 


8         TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

The  Posterior  Gland  lies,  as  a  rule,  laterally  to  the  anterior 

facial  vein. 

The  Submaxillary  Lymph-glands  take  care  of  the  lymph  from 
the  largest  part  of  the  face,  especially  the  lips,  external  nose, 
cheeks,  anterior  part  of  the  lids,  floor  of  the  mouth,  teeth  and 
gums,  mucous  membranes  of  the  cheeks  and  anterior  part  of  the 
mucous  membrane  of  the  nose.  The  efferent  vessels  pass  into 
the  superficial  and  deep  cervical  glands. 

The  Submental  Lymph-glands  are  one  to  four  in  number  and 
are  located  in  the  triangle  bounded  by  the  anterior  bellies  of  the 
Digastric  muscles  and  the  Hyoid  bone.  They  drain  the  integu- 
ment of  the  chin,  central  portion  of  the  skin  of  the  lower  lip, 
the  mucous  membrane  of  the  corresponding  portion  of  the  al- 
veolar border  of  the  mandible,  the  floor  of  the  mouth  and  the 
tip  of  the  tongue.  The  efferent  vessels  pass  into  the  submaxil- 
lary  lymph-glands. 

The  Retro-pharyngeal  Lymph-glands  are  usually  two  in 
number  and  located  behind  the  pharynx,  at  the  junction  of  its 
posterior  and  lateral  surface,  on  a  level  with  the  Atlas.  The 
afferent  vessels  come  from  the  muscles  and  fascia  in  front  of 
the  vertebrae,  nasal  fossae  and  accessory  cavities,  nasopharynx, 
eustachian  tube  and  possibly  from  the  cavity  of  the  tympanum. 
The  efferent  vessels  pass  into  the  deep  cervical  glands. 

The  Deep  Cervical  Glands  are  numerous,  fifteen  to  thirty  in 
number,  lying  along  the  carotid  artery  and  internal  jugular 
vein.  The  chain  extends  from  the  apex  of  the  mastoid  process 
of  the  temporal  bone  to  the  junction  of  the  internal  jugular  and 
subclavian  veins;  they  may  be  divided  into  the  following  groups 
and  subgroups: 

The  Superior  Deep  Cervical  Glands  are  located  on  the  lateral 
side  of  the  neck,  especially  in  the  superior  carotid  triangle  and 
the  upper  part  of  the  occipital  triangle;  this  part  of  the  chain 
hence  extends  from  the  tip  of  the  mastoid  process  to  the  region, 
where  the  common  carotid  artery  is  crossed  by  the  Omohyoid 
muscle. 

The  Mesial  group  is  located  in  the  superior  carotid  triangle 
in  immediate  vicinity  of  the  large  vessels. 


ANATOMICAL  RESUMfi  9 

The  Lateral  group  is  located  in  the  upper  angle  of  the  occipital 
triangle. 

The  Superior  Deep  Cervical  Glands  take  care  of  the  lymph 
from  the  head  and  all  the  parts  of  the  upper  neck  region.  The 
efferent  vessels  pass  into  the  inferior  deep  cervical  glands. 

The  Inferior  Deep  Cervical  Glands  are  also  called  the  Supra- 
clavicular  Glands  and  lie  below  the  Omohyoid  muscle  in  the 
subclavian  triangle. 

The  Mesial  Group  comprises  a  few  glands  which  lie  behind 
the  internal  jugular  vein.  The  efferent  vessels  from  this  group 
unite  with  some  from  the  superior  mesial  group;  the  collecting 
vessels  finally  unite  and  form  the  jugular  trunk  or  empty  directly 
into  the  thoracic  duct  or  right  lymphatic  duct  respectively. 
The  lateral  group  is  located  in  the  subclavian  triangle  proper. 
These  glands  are  connected  with  the  superior  lateral  group  and 
also  with  the  axillary  lymph-glands.  The  efferent  vessels  help 
to  form  the  jugular  trunk. 

The  Inferior  Deep  Cervical  Glands  take  care  of  the  lymph 
from  the  lower  neck  region,  especially  the  thyroid  gland  and  in- 
directly from  the  part  drained  by  the  superior  deep  cervical 
glands,  also  from  the  pretracheal  glands.  The  efferent  vessels 
form  the  jugular  trunk  from  where  the  lymph  passes  to  the  tho- 
racic duct  or  right  lymphatic  duct  respectively. 

The  Prelaryngeal  Glands  usually  lie  on  the  middle  crico- 
thyroid  ligament  between  the  two  Crico-thyroid  muscles.  They 
drain  the  anterior  part  of  the  larynx,  from  the  free  border  of 
the  vocal  cords,  downwards  to  the  beginning  of  the  trachea, 
also  part  of  the  thyroid  gland;  the  efferent  vessels  pass  into  the 
deep  cervical  and  pretracheal  glands. 

The  Pretracheal  Glands  are  located  below  the  isthmus  of  the 
thyroid  in  front  of  the  trachea;  they  are  of  small  size  and  usually 
one  to  three  in  number;  the  afferent  vessels  come  from  the  thyroid 
and  prelaryngeal  glands;  the  efferent  vessels  empty  into  the 
supraclavicular  glands. 


io       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

AREAS  OF  LYMPHATIC  DRAINAGE  OF  HEAD  AND  NECK 

The  Skin. — From  the  forehead,  nose,  lips  and  chin  region, 
the  lymph  travels  to  the  submental  and  submaxillary  lymph- 
glands;  the  further  back  we  come  on  the  lateral  surface  of  the 
face,  the  more  regularly  are  the  parotid  glands  interposed  and 
even  the  superficial  cervical  glands;  the  deep  cervical  lymph- 
glands  constitute  the  second  station  for  this  area. 

The  Eye. — The  External  Eye:  The  lymph- vessels  of  the  eye- 
lids and  the  conjunctiva  form  two  parts : 

The  mesial  vessels  correspond  to  the  angular  artery  and  collect 
the  lymph  from  the  internal  half  of  the  eyelids  and  conjunctiva 
and  pass,  as  a  rule,  to  the  submaxillary  lymph-glands. 

The  lateral  vessels  correspond  to  the  transverse  facial  artery. 
They  arise  from  the  greatest  part  of  the  upper  eyelid,  lateral 
half  of  the  lower  and  corresponding  part  of  the  conjunctiva  and 
run  to  the  parotid  lymph-glands. 

The  Internal  Eye:  No  true  lymphatic  vessels  have  been 
demonstrated  in  the  sclera,  lens  or  vitreous  humor. 

The  Ear. — The  External  Ear  is  drained  by  the  auricular  and 
deep  cervical  glands. 

The  Middle  Ear  and  Auditory  Canal:  The  auricular  glands 
drain  the  lateral  portion;  the  retro-pharyngeal  and  deep  cervical 
the  mesial  portion. 

The  Internal  Ear:  Nothing  is  known  of  its  lymphatics. 
The  Nasal  Cavity.— The  lymph  of  the  nares  travels  in 
two  directions:  from  the  most  anterior  part  it  goes  to  the 
submaxillary  glands,  but  the  main  stream  of  lymph  from 
the  posterior  portion  travels  along  the  lateral  wall  of  the 
pharynx  to  the  lateral  retro-pharyngeal  and  the  deep  cervical 
glands. 

Little  is  known  of  the  lymphatics  of  the  accessory  sinuses  of 
the  nose.  The  lymph  from  the  frontal  sinus  is  taken  care  of 
by  the  lateral  retro-pharyngeal  and  the  deep  cervical  glands; 
the  lymphatics  of  the  superior  maxillary  sinus  travel  to  the 
submaxillary  glands. 

The  Gums.— The  lymph-vessels  of  the  gums  have  been  studied 


nfra-orbitat 


Tonsi 


Tonsilar 
gland 


Lymphatics  of 

teeth  of 
upper  jaw 


mphatics  of 
teeth  of 
lower  jaw 

Submax. 
glands 


Superior  deep 
cervical  glands 


PLATE  V. — A  schematic  presentation  of  the  lymphatics  of  the  teeth  and  tonsils  into  the  deep 

tonsillar  gland. 


ANATOMICAL  RfiSUMfi  u 

by  G.  SCHWEITZER,  whose  results  P.  BARTELS  summarizes  as 
follows : 

"The  gums  are  traversed  by  an  extremely  fine  and  delicate 
network  of  lymphatic  capillaries;  from  these,  two  groups  of 
vessels  arise. 

"The  outer  group  forms  a  plexus,  which  encircles  the  alveolar 
processes  of  the  jaws  along  the  lower  and  upper  folds  of  the 
mucous  membrane  and  forms  mesial  anastomoses.  The  regional 
lymph-glands  are  the  submaxillary,  submental  and  deep  cervical 
glands. 

"The  inner  vessels  of  the  gums  of  the  upper  jaw  travel  through 
the  mucous  membrane  of  the  hard  palate,  or  over  the  soft  palate 
and  pharyngeal  wall  downwards  toward  the  deep  cervical  glands. 
In  the  lower  jaw  the  vessels  from  the  incisor  region  travel  to  the 
anterior  submaxillary  glands  and  the  balance  to  the  deep  cervi- 
cal glands." 

The  Teeth. — The  existence  of  lymphatics  in  the  tooth-pulp 
has  long  been  denied  until  G.  SCHWEITZER  succeeded  in  demon- 
strating them.  He  says,  "The  presence  of  lymphatics  in  the 
pulp  of  the  fully  developed  and  embryonal  teeth  has  been  demon- 
strated, but  their  number  and  course  are  not  yet  completely 
established." 

The  collecting  vessels  from  the  teeth  of  the  upper  jaw  most 
probably  unite  and  pass  through  the  infra-orbital  foramen  and 
travel  to  the  submaxillary  glands. 

The  regional  lymph-glands  of  the  teeth  of  the  lower  jaw  have 
not  been  demonstrated  absolutely,  but  from  analogy,  with  the 
lymphatics  of  the  gums,  it  may  be  concluded  that  they  are 
the  submaxillary  and  deep  cervical  glands.  (See  Schweitzer's 
Table,  p.  12.) 

The  Oral  Cavity. — The  lymph-vessels  of  the  mouth  pass 
mainly  to  the  submaxillary  and  superficial  cervical  glands. 
From  the  main  part  of  the  tongue,  and  posterior  part  of  the  oral 
cavity,  the  lymph  goes  to  the  mesial  group  of  the  superior  deep 
cervical  glands. 

The  Throat. — The  lymphatics  of  the  upper  and  posterior 
region  of  the  throat  travel  to  the  retro-pharyngeal  glands,  whence 


12        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 
SCHWEITZER'S  TABLE 


From  region 
of 

The  upper  jaw  to  the  submax- 
illary  glands 

The  lower  jaw  to  the  submax- 
illary  glands 

Anter.  Gl. 

Mesial  Gl. 

Post.  Gl. 

Anter.  Gl. 

Mesial  Gl. 

Post.  Gl. 

Incisors 

Occasion- 
ally one 
vessel 

About 

V« 

About 

Ve 

About 
l/J 

About 

2/3 

Occasion- 
ally one 
vessel 

Premolars 

o 

about  *lz 

about  Vs 

seldom  one 
vessel 

nearly  all 

o 

Molars 

o 

nearly  % 

somewhat 
more   than 

K 

occasion- 
ally one 
vessel 

nearly  all 

occasion- 
ally one 
vessel 

they  go  to  the  deep  cervical  glands.  The  lymph  from  the  lateral 
walls  of  the  pharynx,  especially  from  the  tonsillar  region,  is 
taken  care  of  by  the  mesial  group  of  the  deep  cervical  glands. 

Lymph-vessels  from  the  anterior  and  lower  part  of  the  throat 
penetrate  the  thyreo-hyoid  membrane  and  join  the  vessels  from 
the  region  of  epiglottis  and  larynx  and  arrive  at  the  mesial  group 
of  the  deep  cervical  glands. 

The  Larynx. — The  lymph-vessels  from  the  upper  portion  of 
the  larynx  travel  the  same  route  as  the  vessels  from  the  anterior 
and  lower  part  of  the  pharynx,  penetrate  the  thyreo-hyoid  mem- 
brane and  go  to  the  mesial  group  of  the  deep  cervical  glands. 

The  lymph  from  the  region  of  the  anterior  subglottal  space 
is  taken  care  of  by  delicate  vessels  which  penetrate  the  crico- 
thyreo-hyoid  membrane  and  go  to  the  laryngeal  glands,  while 
the  lymphatics  of  the  mucous  membrane  of  the  posterior  wall 
of  the  larynx  go  to  the  pretracheal  glands. 

TONSILLAR  RING  OF  WALDEYER 

The  ensemble  of  lymphoid  tissue,  the  palatine,  lingual  and 
pharyngeal  tonsils,  situated  at  the  entrance  of  the  respiratory 
and  digestive  passages,  form  an  almost  complete  ring  commonly 
known  as  "Waldeyer's  ring." 

The  Palatine  Tonsil  or  Faucial  Tonsil.— The  Palatine  Tonsil 


ANATOMICAL  RESUME  13 

consists  of  a  rounded  mass  of  lymphoid  tissue  on  each  side  of 
the  fauces.  The  tonsil  varies  markedly  in  size,  but  in  the  young 
adult  averages  about  twenty  rh.  m.  in  height,  fifteen  m.  m.  in 
width  and  twelve  m.  m.  in  thickness.  The  lateral  surface  is 
covered  by  the  capsule  which  is  continuous  with  the  pharyngeal 
aponeurosis.  The  pharyngeal  surface  is  covered  with  the  mucous 
membrane  of  the  pharynx  and  presents  the  openings  of  various 
crypts,  twelve  to  fifteen  in  number,  lined  with  stratified  epithe- 
lium. 

The  Blood  Supply. — The  tonsils  are  very  rich  in  blood  supply. 
The  most  important  arteries  are  the  ascending  palatine  and  ton- 
sillar  branches  of  the  facial  artery,  dorsalis  linguae  of  the  lingual, 
ascending  pharyngeal  of  the  external  carotid  and  the  descending 
palatine  branch  of  the  internal  maxillary  artery. 

The  Lymphatics  of  the  Tonsils  are  not  well  understood. 
HENKLE  5  in  a  recent  rather  remarkable  series  of  experiments 
tried  to  prove  that  the  tonsils  were  concerned  in  draining  the 
mucous  membrane  of  the  nose  and  gums,  thus  substantiating 
the  findings  of  V.  LENART,  FRANKEL  and  WRIGHT.  But  KARL 
AMERSBACH  6  has  still  more  recently  reported  the  results  of  his 
own  experiments  carried  out  in  nearly  the  same  manner  as 
HENKLE'S,  except  as  G.  B.  WOOD  7  remarks,  that  he  was  more 
careful  in  the  method  of  injection.  In  his  experiments  on  human 
beings  he  injected  carbon  pigments  into  the  mucosa  of  the  nose 
and  mouth  and  was  in  no  instance  able  to  recover  any  part  of 
them  in  the  tonsils.  In  his  experiments  on  dogs  he  showed  that 
these  particles  travelled  down  to  the  submaxillary  glands,  hence 
along  a  route  anatomically  demonstrated  by  our  foremost 
anatomists. 

G.  B.  WOOD'S  contention  is  thus  upheld  that  as  far  as  we  know 
there  are  no  afferent  lymph-vessels  running  to  the  parenchyma 
of  the  tonsils;  neither  have  any  perilymphatic  spaces  been  demon- 
strated. The  efferent  lymph-vessels  empty  into  the  superior 
deep  cervical  glands,  especially  the  so-called  tonsillar  gland, 
lying  under  the  anterior  border  of  the  Sterno-cleido-mastoid 
muscle,  just  behind  the  angle  of  the  mandible. 

The  Functions  of  the  Tonsils,  as  that  of  the  Waldeyer's  Ring 


i4       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

in  general  is,  from  their  important  anatomical  position,  to  be 
considered  as  one  of  direct  defense  against  microbic  invasion. 
Absorption  through  the  intact  tonsillar  epithelium  is  a  disputed 
question. 

According  to  some  investigations  the  tonsils  per  se  actually 
antagonize  the  entrance  to  their  interior  of  infectious  germs. 
But  if  they  are  once  absorbed  the  anatomical  structure  of  the 
gland  will  delay  their  passage,  thus  giving  the  ever  present 
leucocytes  a  chance  to  exercise  their  phagocytic  power.  Another 
protective  function  of  the  tonsil  is  possibly  shown  by  the  so- 
called  Stohr's  phenomena;  the  tonsils  are  traversed  by  an  enor- 
mous number  of  leucocytes  which  exercise  a  kind  of  migration 
toward  the  oral  cavity.  Some  investigators  believe  that  the 
tonsils  have  an  internal  secretion  but  exact  proof  of  its  existence 
is,  as  yet,  wanting. 

The  Lingual  Tonsils  are  small  lymphatic  organs  situated  on 
either  side  of  the  central  line  at  the  base  of  the  tongue;  each 
tonsil  has  usually  one  crypt,  lined  with  a  continuation  of  the 
surface  stratified  squamous  epithelium. 

The  Pharyngeal  Tonsils,  or  Tonsils  of  Luschka,  consist  of  a 
mass  of  lymphoid  tissue  lying  in  the  vault  of  the  naso-pharynx. 
They  are  covered  by  columnar  ciliated  epithelium.  Hypertrophy 
of  these  tonsils  constitutes  what  is  known  as  adenoids. 

VISCERAL  LYMPHATIC  GLANDS  OF  THE  THORAX 

The  painstaking  research  on  the  lymphoid  tissue  hi  the  lung, 
as  done  by  W.  S.  MILLER,*  is  of  interest  in  that  it  shows  the 
minute  development  of  the  lymphatic  system  in  the  lung  proper 
and  the  distribution  of  lymphoid  tissue  in  its  relation  to  the 
bronchi,  blood  and  lymph-vessels  and  the  pleura.  The  lymphoid 
tissue  in  the  lung  may  be  in  the  form  of  lymph-nodes,  lymph- 
follicles  or  small  masses  of  lymphoid  tissue.  Lymph-nodes  in 
the  normal  lung  are  found  associated  with  the  laiger  divisions 
of  the  bronchi.  They  are  situated  at  the  place  where  branching 
takes  place.  In  the  normal  lung  lymph-nodes  are  not  present  in 
the  pleura.8 


Paratracheal 
I. 

Rt.  recurrent 
laryng.  nerve 

Rt.Trocheo- 
bronchia'  gls. 


Poratracheal 
gls. 


Left  recurr.  laryng. 
nerve 


Left  trachea- 
bronchial  gls. 


Broncho- 

pulmonary 

glands 


Broncho- 
pulmonary 
glands 


PLATE  VI.— Glands  in  relation  to'the  trachea  and  the  large  bronchi.     (After  Lukiennikow.) 


ANATOMICAL  RfiSUME  15 

The  smaller  masses  of  lymphoid  tissue  may,  like  the  lymph- 
nodes,  act  as  filters  interpolated  in  the  lymph  circulation.  They 
also  serve  as  centres  to  which  the  phagocytes  carry  their  col- 
lected material.  According  to  MILLER  9  the  flow  in  the  lymphat- 
ics of  the  bronchi,  of  the  arteries,  of  the  main  venous  trunks 
and  the  greater  part  of  the  pleura  is  toward  the  hilum  of  the 
lung.  In  the  lymphatics  about  the  veins,  the  flow,  in  those 
vessels  which  are  situated  just  beneath  the  pleura  and  com- 
municate with  the  pleural  network  of  lymphatics,  may  be  towards 
the  pleura. 

The  Visceral  Lymph-glands  of  the  Thorax  form  two  main 
groups — the  mediastinal  and  bronchial,  which  are  divided  into 
the  following  sub-groups. 

The  Anterior  Mediastinal  Glands  are  located  in  the  anterior 
mediastinum  in  front  of  the  aorta  and  left  innominate  vein. 
They  are  six  to  seven  in  number  and  drain  the  heart,  pericardium, 
thymus  gland,  anterior  mediastinum  and  a  great  part  of  the 
liver.  The  efferent  vessels  pass  into  the  right  and  left  broncho- 
mediastinal  trunks  respectively. 

The  Posterior  Mediastinal  Glands  lie  behind  the  pericardium 
along  the  thoracic  aorta;  they  drain  the  posterior  portion  of  the 
diaphragm  and  pericardium  and  send  their  efferent  vessels  to 
the  right  and  left  lymphatic  ducts. 

The  Bronchial  Glands  are  extremely  numerous  and  are,  ac- 
cording to  their  location,  divided  into  the  following  sub-groups : 

The  Tracheo-bronchial  Lymph-glands  are  situated  in  the 
lateral  angles,  between  the  trachea  and  the  bronchus  on  each 
side.  Their  afferent  vessels  come  from  the  other  group  of  bron- 
chial glands  and  adjacent  parts  of  the  trachea  and  bronchi.  The 
efferent  vessels  pass  to  the  broncho-mediastinal  trunk;  occa- 
sionally one  vessel  passes  to  the  lateral  group  of  the  supra- 
clavicular  glands. 

Lymph-glands  of  the  Bifurcation  are  located  in  the  angle 
between  the  two  main  bronchi.  They  are  nine  to  twelve  in 
number  and  drain  the  adjacent  parts;  they  also  receive  the 
efferent  vessels  of  the  broncho-pulmonary  glands;  their  efferent 
vessels  pass  to  the  tracheo-bronchial  glands. 


Z6       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

The  Broncho-pulmonary  Glands  are  embedded  in  the  hilus 
of  the  lung  and  drain  the  lung  substance  directly  or  through  the 
pulmonary  glands;  their  efferent  vessels  may  go  directly  to  the 
tracheo-bronchial  glands,  or  via  those  of  the  bifurcation. 

The  Pulmonary  Lymph-glands  are  situated  in  the  lung  sub- 
stance which  they  drain ;  the  efferent  vessels  pass  into  the  broncho- 
pulmonary  glands. 

LYMPHATIC  GLANDS  OF  THE  ABDOMEN 

The  Mesenteric  Glands  are  the  most  important.  They  are 
located  between  the  layers  of  the  mesentery  and  vary  in  number 
from  100  to  250.  They  form  three  main  groups,  the  outer,  middle 
and  inner. 

The  outer  group  lies  close  to  the  wall  of  the  small  intestines 
and  contains  the  smallest  glands. 

The  middle  group  consists  of  somewhat  larger  glands  and 
corresponds  in  position  to  the  narrowing  of  the  mesentery  toward 
its  root. 

The  inner  group  lies  on  the  root  of  the  mesentery  and  contains 
the  largest  glands. 

The  Mesenteric  Glands  take  care  of  the  lymph  from  the  small 
intestine  except  the  duodenum  and  receive  the  efferent  vessels 
from  the  mesocolic  and  ileo-caecal  glands.  The  efferent  channels 
pass  to  the  intestinal  trunk. 

The  Mesocolic  Glands  are  found  between  the  layers  of  the 
mesentery  of  the  large  intestine;  they  are  from  20  to  30  in  number 
and  receive  their  afferent  vessels  from  the  large  intestine,  sending 
their  efferent  ones  to  the  mesenteric  lymph-glands. 

The  Caecal  Lymph-glands  may  be  divided  into  the  following 
groups: 

The  Pre-caecal,  on  the  anterior  surface  of  the  caecum,  the 
Retro-caecal,  on  the  posterior  surface  of  the  caecum,  and  the 
Ileo-caecal  surrounding  the  termination  of  the  ileo-caecal  artery. 

The  Lymph  from  the  caecum  is  sent  to  the  pre-cascal  and  retro- 
caecal  glands,  from  where  it  passes  to  the  ileo-caecal  and  mesenteric 
glands. 


ANATOMICAL  RfiSUMfi  17 

The  Appendicular  Lymph-glands  are  very  inconsistent  as  to 
location  and  number;  they  surround  the  appendicular  artery 
and  drain  the  appendix  sending  their  efferent  vessels  to  the 
ileo-caecal  glands. 

The  Gastric  Glands. — The  Superior  Gastric  Glands  lie  between 
the  folds  of  the  lesser  omentum  along  the  lesser  curvature  of 
the  stomach,  following  the  course  of  the  right  and  left  gastric 
arteries. 

The  inferior  Gastric  Glands  are  located  in  the  folds  of  the 
gastro-colic  ligaments  along  the  greater  curvature  following 
the  course  of  the  right  and  left  gastro-epiploic  arteries. 

The  glands  take  care  of  the  lymph  from  the  walls  of  the  stomach 
and  send  their  efferent  vessels  to  the  pancreatico-splenic  glands 
from  where  it  passes  to  the  cceliac  glands. 

The  Hepatic  Glands  lie  in  the  hepato-duodenal  ligament  along 
the  course  of  the  hepatic  artery  and  receive  their  afferent  vessels 
from  the  liver  and  gall  bladder,  pylorus,  duodenum  and  head 
of  the  pancreas.  The  efferent  vessels  pass  to  the  cceliac  glands. 

The  Pancreatico-splenic  Glands  are  located  behind  the  pan- 
creas in  the  hilum  of  the  spleen  between  the  folds  of  the  gastro- 
splenic  ligament  along  the  splenic  artery.  They  receive  the 
lymph  from  the  pancreas,  duodenum,  liver,  stomach  and  spleen 
and  send  their  efferent  vessels  into  the  cceliac  glands. 

The  Cceliac  Lymph-glands  form  the  upper  intestinal  glands 
and  lie  behind  the  pancreas,  duodenum  and  pylorus,  in  front 
of  the  abdominal  aorta,  between  and  behind  the  layers  of  the 
transverse  mesocolon  and  lesser  omentum.  They  receive  the 
lymph  from  the  digestive  organs,  lying  above  the  transverse 
mesocolon,  having  previously  passed  through  intermediate 
lymph-glands.  The  efferent  vessels  help  to  form  the  intestinal 
lymphatic  trunk. 

The  Lumbar  Lymph-glands  are  situated  on  the  posterior 
wall  of  the  abdomen  behind  the  parietal  peritoneum,  in  front 
of  the  Psoas  major  and  Quadratus  lumborum  muscles  and  sur- 
round the  abdominal  aorta,  especially  on  its  posterior  surface. 
These  glands  receive  the  efferent  vessels  of  the  iliac,  hypo-gastric, 
sacral  and  mesocolic  glands,  and  afferent  vessels  from  the  kidneys, 


i8       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

adrenals,  testicles,  fundus  of  uterus,  tubes  and  ovaries,  the  deep 
back  muscles  and  from  the  under  surface  of  the  vertebral  part 
of  the  diaphragm.  Their  efferent  vessels  go  to  form  the  lateral 
tributaries  of  the  thoracic  duct— namely,  the  right  and  left 
lumbar  trunks. 

LYMPHATIC  GLANDS  OF  THE  PELVIS 

The  Ano-Rectal  Glands  are  located  in  the  lower  part  of  the 
true  pelvis  on  the  lateral  sides  of  the  rectum;  their  efferent 
vessels  convey  the  lymph  from  the  mucous  membrane  and 
muscular  coat  of  the  rectum  and  from  the  mucous  membrane 
of  the  upper  part  of  the  anal  canal;  the  efferent  vessels  pass  into 
the  superior  hemorrhoidal  glands. 

The  Para-uterine  Glands  are  embedded  in  the  folds  of  the 
broad  ligament  close  to  the  neck  of  the  uterus,  which  organ  they 
also  drain ;  the  efferent  vessels  pass  into  the  hypo-gastric  lymph- 
glands. 

The  Vesicular  Glands  are  located  on  the  anterior  and  lateral 
walls  of  the  bladder,  the  walls  of  which  organ  they  also  drain, 
sending  their  efferent  vessels  into  the  external  iliac  glands. 

The  Hemorrhoidal  Glands  lie  in  the  meso-rectum  following 
the  course  of  the  superior  hemorrhoidal  artery;  these  glands 
drain  the  pelvic  part  of  the  rectum  and  receive  the  efferent 
vessels  of  the  ano-rectal  glands,  sending  their  own  efferents  to 
the  inferior  mesenteric  glands. 

The  Sacral  Glands  are  located  on  the  anterior  surface  of  the 
sacrum.  They  take  care  of  the  lymph  from  the  adjacent  wall 
of  the  pelvis,  the  afferent  vessels  anastomosing  with  those  of 
the  rectum  and  prostate  gland;  the  efferent  vessels  pass  to  the 
hypogastric  and  lumbar  glands. 

The  Hypogastric  Glands  lie  on  the  lateral  walls  of  the  pelvis, 
following  the  course  of  the  hypogastric  vessels;  the  afferent  vessels 
receive  lymph  from  the  gluteal  region,  hip  joint,  internal  surface 
of  the  thigh,  perineum,  urogenital  tract,  upper  third  of  the 
vagina,  uterus,  prostate  gland,  seminal  vesicles  and  rarely  from 
the  penis.  The  efferent  vessels  are  sent  to  the  common  iliac 
and  lumbar  glands. 


ANATOMICAL  RESUME  19 

The  Iliac  Glands  follow  the  course  of  the  external  and  com- 
mon iliac  vessels  from  the  femoral  ring  to  the  fifth  lumbar  verte- 
bra. They  receive  the  efferent  vessels  of  the  inguinal  glands, 
especially  Rosenmuller's  gland,  the  inferior  epigastric  and  the 
hypogastric  glands;  the  iliac  glands  also  drain  the  penis,  clitoris, 
vagina,  bladder  and  the  abdominal  wall  below  the  umbilicus; 
the  efferent  vessels  go  into  the  lumbar  glands. 

LYMPH-GLANDS  OF  THE  UPPER  EXTREMITIES 

The  Antibrachial  Glands  lie  along  the  course  of  the  radial  and 
ulnar  arteries. 

The  Superficial  Cubital  or  the  Supra-trochlear  Glands  are 
located  just  above  the  medial  epicondyle  to  the  mesial  side  of 
the  basilic  vein  where  it  pierces  the  deep  fascia. 

The  Deep  Cubital  Glands  lie  deep  in  the  cubital  region  near 
the  large  vessels. 

The  Axillary  Glands  drain  the  upper  part  of  the  thoracic  wall 
and  the  upper  extremities;  they  vary  markedly  in  number  from 
eight  or  ten,  to  fifty  or  more.  P.  BARTELS  divides  them  into  the 
following  groups : 

The  Pectoral  Glands  are  located  along  the  lower  border  of  the 
Pectoralis  major  muscle  and  drain  the  mammary  gland  and  front 
and  side  of  thorax;  they  send  their  efferent  vessels  into  the  inter- 
mediate and  infra-clavicular  groups. 

The  Subscapular  Glands  follow  closely  the  subscapular  vessels 
and  receive  their  afferent  vessels  from  the  dorsal  surface  of  the 
thorax.  The  efferent  vessels  pass  to  the  brachial  group. 

The  Brachial  Glands  lie  the  deepest  of  the  axillary  glands 
behind  the  axillary  vessels  and  receive  the  lymph  from  the  super- 
ficial and  deep  lymphatics  of  the  arm;  they  send  their  efferent 
vessels  to  the  intermediate  and  infra-clavicular  groups. 

The  Subpectoral  Glands  are  located  beneath  the  Pectoralis 
minor  muscle  to  the  mesial  side  of  the  axillary  vessels,  draining 
the  region  supplied  by  the  acromio-thoracic  artery. 

The  Intermediate  or  Central  Glands  are  situated  deep  in  the 
axilla  along  the  axillary  artery  below  the  origin  of  the  long 


20       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

thoracic  artery;  they  receive  the  efferent  vessels  of  the  other 
groups,  sending  their  own  to  the  infra-clavicular  group. 

The  Infra-clavicular  Glands  lie  between  the  upper  border  of 
the  Pectoralis  minor  muscle  and  the  clavicle  to  the  mesial  side 
of  the  subclavian  vein.  The  efferent  vessels  unite  to  form  the 
subclavian  trunk:  anastomosis  does  sometimes  exist  with  the 
supra-clavicular  glands. 

LYMPHATIC  GLANDS  OF  THE  LOWER  EXTREMITIES 

The  Anterior  Tibial,  The  Popliteal  and  the  Posterior  Tibial 
Glands  take  care  of  the  lymph  of  the  lower  extremity  sending 
it  through  the  inguinal  glands. 

The  Inguinal  Glands  are  divided  into  the  superficial  and  deep 
groups:  the  former  is  divided  in  two  sub-groups,  the  superficial 
inguinal  and  superficial  sub-inguinal.  ' 

The  Superficial  Inguinal  Glands  are  located  above  a  line 
drawn  through  the  point  where  the  saphenous  vein  pierces  the 
fascia  of  the  fossa  ovalis.  They  He  just  below  Poupart's  ligament. 

The  Superficial  Sub-inguinal  Glands  are  located  just  below 
the  above  mentioned  line. 

The  Superficial  Group  drain  the  skin  of  the  lower  extremity, 
the  gluteal  region,  perineum,  abdominal  wall,  scrotum,  anus, 
prepuce  of  clitoris,  and  sometimes  glans  penis  and  clitoris.  The 
efferent  vessels  pass  into  the  external  iliac  glands. 

The  Deep  Inguinal  Glands  lie  beneath  the  fascia  lata.  They 
are  small  in  size  and  few  in  number.  The  gland  of  Rosenmuller 
is  the  largest  and  is  located  in  the  femoral  ring.  These  glands 
receive  some  of  the  efferent  vessels  of  the  superficial  groups  and 
send  their  own  channels  to  the  iliac  glands. 


CHAPTER  in 
PHYSIOLOGICAL  CONSIDERATIONS 

Composition  of  the  Lymph. — RUDBECK,  one  of  the  discoverers 
of  the  lymphatic  system  (1653)  said  that  the  lymph  is  a  water- 
clear  liquid  of  salty  taste  which  coagulates  spontaneously. 
TIGERSTEDT  remarks  that  our  present  knowledge  is  not  much 
more  complete. 

The  chemical  composition  of  lymph  corresponds  to  that  of 
the  blood  plasma  with  slight  variations  in  the  albumen  contents. 
TIGERSTEDT  gives  the  following  percentage  composition  of  human 
lymph:  10 

Water 93-96% 

Fibrin 0.04-0.05% 

Albumen 3.5  -4.3  % 


Solids 4-  7% 


Inorganic  salts  (ashes) 0.7  -0.8  % 

Fat 0.4  -0.9  % 

Cholesterin  and  Lecithin 


In  examining  the  lymph  from  a  dog,  HAMMERSTEN  found  only 
traces  of  oxygen  but  about  42  vol.%  of  carbonic  acid;  hence  a 
greater  quantity  than  in  the  arterial  blood  but  less  than  hi  the 
venous. 

Microscopical  Examination  of  the  Lymph. — Microscopical  ex- 
amination of  the  lymph  reveals  the  presence  of  white  blood-cells 
in  varying  numbers  and  a  few  red  blood-cells. 

During  recent  years  many  investigations  have  been  made  as 
to  the  physiological  action  of  the  lymph  itself.  ASHER  and 
BARBERA  reinjected  neck  lymph  secured  by  passive  massage  of 
the  neck,  into  the  central  end  of  the  internal  carotid  artery  and 
found  some  changes  in  the  blood  pressure.  According  to  the 
same  authors,  the  substance  in  the  lymph  producing  these  effects 
on  the  vasomotor  centre,  is  produced  in  the  tissue  and  rendered 
innocuous  or  ineffective  in  the  lymph-glands;  massage  of  the 


22 


TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 


head  and  neck  prevented  this  in  the  experiments.  CARLSON, 
GREER  and  BECHT  "  proved  that  the  lymph  itself  has  a  lympha- 
gogue  action,  probably  due  to  the  presence  of  a  hormone  pro- 
duced in  the  normal  activity  of  the  tissues. 

Circulation  of  the  Lymph.— The  movement  of  the  lymph  is 
always  a  centripetal  one,  from  the  radicals  of  the  lymphatic 
system  toward  the  larger  vessels.  Many  factors  are  concerned 
in  the  circulation  of  the  lymph.  The  tissue  tension  without 
question  plays  an  important  role.  When  the  tissue-liquid  is 
increased,  the  tissue  tension  is  consequently  raised  and  thus 
the  lymph-stream  accentuated.  Muscular  contraction  produces 
the  same  result,  increasing  the  tissue-tension.  The  upward 
movement  of  the  lymph  in  the  thoracic  duct  is  mainly  caused 
by  the  inspiratory  act  producing  a  negative  pressure  in  the 
thoracic  cavity.  The  presence  of  valves  removes  the  possibility 
of  backward  flow. 

Formation  of  the  Lymph. — The  formation  of  lymph  is  as  yet  a 
disputed  question.  The  old  theory  defended  by  LUDWIG  and 
his  pupils,  taught  that  the  lymph  was  derived  from  the  blood- 
plasma  by  a  simple  process  of  nitration,  depending  upon  the 
greater  pressure  in  the  blood-channels.  But  recent  investiga- 
tions seem  to  disprove  this  conception. 

The  difference  in  pressure  and  osmotic  tension  between  the 
arterial  capillaries  and  the  surrounding  tissue  and  lymphatic 
radicals  is  undoubtedly  a  partial  factor  in  formation  of  the  lymph, 
but  CARLSON,  GREER  and  LUCKHARD  12  showed  that  the  chloride 
content  in  the  lymph  was  larger  than  in  the  blood,  thus  rendering 
the  nitration  and  transudation  theories  of  lymph-formation 
untenable. 

HEEDENHAIM  proved  that  the  injection  of  certain  substances, 
lymphagogues,  into  the  blood-stream  resulted  in  increased 
lymph-formation  without  increasing  the  blood  pressure.  He 
proposed  the  theory  that  the  cells  of  the  capillary  walls  have  a 
secretory  function,  thus  being  partially  responsible  for  the 
lymph-formation. 

ASHER  has  still  more  recently  emphasized  the  relation  between 
lymph-formation  and  the  activity  of  the  tissues;  he  considers 


PHYSIOLOGICAL  CONSIDERATIONS  23 

the  lymph  a  product,  a  secretion  of  the  functionating  tissue 
cells. 

CARLSON,  GREER  and  BECHT  propose  the  theory  that  one  of 
the  normal  mechanisms  of  lymph-formation  is  a  hormone,  pro- 
duced in  the  normal  activity  of  the  tissues  and  acting  by  aug- 
menting the  normal  secretory  activity  of  the  capillary  endothe- 
lium. 

According  to  some  authors  the  phenomena  observed  in  the 
lymph-formation  can  be  explained  by  physical-chemical  laws. 
STARLING  13  believes  that  the  lymphagogue  action  of  certain 
substances  depends  upon  an  injurious  effect  upon  the  capillary 
endothelium,  thus  rendering  it  more  permeable. 

The  Lymphatic  Vessels  and  their  Function. — The  lymph- 
vascular  system  may  be  regarded  as  a  drainage  apparatus,  which 
takes  care  of  the  excessive  liquid  present  in  the  body  tissues. 
In  many  tissues  the  lymph-vessels  serve  as  nutrition  carriers, 
e.  g.,  in  the  epithelium  of  the  skin,  cornea  of  the  eye.  The  lacteal 
vessels  of  the  intestinal  villi  have  the  special  function  of  absorb- 
ing the  chyle. 

The  Lymph-glands  and  their  Function. — The  function  of 
the  lymphatic  glands  is  as  yet  not  fully  understood.  The  glands 
participate  in  the  production  of  white  blood-cells  by  the  cellular 
proliferation  in  the  germinal  centres,  proven  by  the  fact  that 
the  lymph  is  richer  in  cellular  elements  after  having  passed 
through  a  chain  of  glands.  A  pathological  proof  of  this  function 
is  found  in  leukaemia,  the  hyperplasia  of  the  lymphatic  glands 
being  associated  with  marked  increase  of  the  white  blood-cells. 

LUCIANI  14  believes  that  many  of  the  catabolic  products  poured 
out  by  the  tissues  into  the  lymph-stream  and  which,  if  directly 
re-absorbed  into  the  blood,  would  exercise  a  toxic  action,  are 
rendered  innocuous  by  the  specific  activity  of  the  numerous 
lymphatic  glands  through  which  they  pass  before  joining  the 
blood. 

The  glands  contain  a  large  number  of  lymphocytes  and  leu- 
cocytes, thus  making  them  of  great  importance  in  the  organ- 
ism's fight  against  infection  of  any  kind. 

The  anatomical  peculiarities  of  the  gland  render  it  a  good 


24       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

filter,  whereby  many  pathogenic  bacteria  may  be  arrested  or 
their  progress  retarded,  giving  the  cellular  elements  a  better 
chance  to  attack  the  invaders. 

The  glands  undergo  marked  changes  during  the  life  of  an 
individual;  they  are  in  then-  fullest  stage  of  development  in 
childhood;  and  as  age  advances  they  become  less  resilient,  the 
connective  tissue  increasing  in  amount,  making  them  less  adapt- 
able for  filters. 

Internal  secretion  is  often  spoken  of  with  regard  to  the  lymph- 
glands,  especially  the  tonsils;  but  nothing  has,  as  yet,  been 
proven  in  this  respect. 


CHAPTER  IV 
ETIOLOGY 

HISTORY 

Before  the  discovery  of  the  Bacillus  tuberculosis  of  KOCH,  the 
etiological  conception  of  enlarged  glands,  especially  of  those  of 
the  neck,  was  very  vague.  The  old  name,  scrofula,  often  in- 
cluded a  variety  of  conditions  such  as  syphilis,  goitre,  carcinoma, 
rickets,  etc.  Struma  was  often  used  in  the  same  sense. 

In  the  early  part  of  the  nineteenth  century  many  investigators 
tried  to  establish  a  relationship  between  scrofula  and  tuberculo- 
sis. The  first  attempts  were  followed  by  negative  results.  VIL- 
LEMIN  *  (1868)  succeeded  in  demonstrating  the  infectiousness 
of  tuberculosis.  He  fed  dogs  with  tuberculous  lung  tissue  and 
thus  produced  the  disease.  He  also  injected  substance  from 
caseating  lymph  glands  into  two  guinea-pigs  with  positive  re- 
sults. But  VILLEMIN'S  views  were  not  generally  accepted.  It 
remained  for  ROBERT  KOCH  to  demonstrate  and  isolate  the 
Bacillus  tuberculosis  (1882).  He  proved  that  the  so-called 
scrofulous  glands  were  tuberculous  in  nature.  KOCH  found  the 
tubercle  bacilli  in  a  number  of  glands,  which  histologically  were 
proven  to  be  tuberculous;  animal  injections  were  also  followed 
by  positive  results. 

BACTERIOLOGY 
BACILLUS  TUBERCULOSIS  HUMANUS 

Morphology. — The  Tubercle  Bacillus  is  a  minute  rod-shaped 
organism  with  slightly  rounded  ends  and  a  somewhat  bent  shape. 
It  varies  in  length  from  1.5  to  3.5  microns  and  in  thickness  from 
0.2  to  0.5  microns.  The  bacilli  occur  singly  or  in  groups,  often 
overlapping  each  other.  A  marked  similarity  to  the  actinomyces 
is  often  shown  by  the  appearance  of  bizarre  forms  with  projecting 


26       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

processes  or  branches,  or  club-shaped  or  beaded  organisms. 
Metachromatic  bodies  of  highly  refractile  power  are  often  found 
in  the  bacilli,  giving  them  a  beaded  appearance.  At  first  these 
were  thought  to  be  spores  but  have  since  been  recognized  as 
vacuoles.  The  tubercle  bacillus  has  no  power  of  movement 
and  does  not  possess  any  flagellas. 

Staining  Characteristics.— The  tubercle  bacillus  does  not 
stain  well  with  ordinary  methods.  KOCH  found  that  the  dye 
must  contain  a  mordant  before  it  takes.  He  used  a  solution  of 
caustic  potash  to  fix  the  stain.  This  method  was  later  modified 
by  EHRLICH  who  found  that  pure  anilin  was  a  better  mordant 
than  potash.  A  still  later  modification  is  that  of  ZIEHL-NIELSON 
where  carbol-fuchsin  is  used.  The  specific  staining  reaction  of 
tubercle  bacillus  is  that  the  color  once  assumed,  is  both  acid  and 
alcohol  fast. 

MUCH  2  discovered  that  in  tuberculous  tissue,  especially  of 
bovine  origin,  where  no  tubercle  bacilli  are  demonstrable  by 
the  ZIEHL  method,  an  organism  is  present  which  can  be  stained 
by  Gram's  method.  A  granular  form,  Much's  granules,  can 
also  be  demonstrated  in  many  cases.  The  real  significance  of 
this  granular  form  is  not  known.  MUCH  and  DEYCKE  consider 
them  as  the  primitive  original  form,  from  which  the  acid-fast 
tubercle  bacilli  have  developed.  MUCH  succeeded  in  changing 
the  non-acid  fast  type  to  the  acid  fast  by  passing  through  a 
guinea-pig.  Many  investigators  believe  that  they  represent 
products  of  disintegration,  (v.  BEHRING,  CORNET,  GEIPEL.) 
According  to  the  more  recent  investigations  of  BITTROLF  and 
MoMOSE,3  no  other  form  of  the  tubercle  bacillus  can  be  demon- 
strated by  MUCH'S  method  than  by  ZIEHL'S,  provided  the 
twenty-four  hour  method  is  employed. 

Culture  Characteristics. — The  tubercle  bacillus  is  a  strict 
aerobic  organism,  requiring  considerable  oxygen  for  its  growth 
and  therefore  grows  only  upon  the  surface  of  the  culture-media. 
The  optimum  temperature  is  37°  C.,  while  the  temperature 
below  29°  C.  or  above  42°  C.  inhibit  its  growth. 

Culture  on  Blood  Serum.— KOCH  was  the  first  to  use  blood 
serum  as  a  culture  medium;  he  succeeded  by  its  use  in  artificially 


ETIOLOGY  27 

cultivating  the  organism.  In  about  two  weeks  the  growth  is 
visible  to  the  naked  eye,  in  the  form  of  dry,  whitish  flakes  which 
increase  in  size  at  the  edges  and  form  small  scale-like  masses 
with  a  wrinkled  surface;  the  layer  is  dry  and  brittle,  pushing 
itself  up  the  side  of  the  tube.  Blood  serum  is  useful  in  isolating 
fresh  virulent  cultures. 

Culture  on  Glycerin  Agar. — Any  of  the  ordinary  culture  media 
will  grow  the  tubercle  bacillus,  if  glycerin  is  added  in  amounts 
°f  3  to  5%.  Glycerin  agar  gives  a  quite  luxuriant  growth  of  the 
organism,  resembling  that  upon  the  blood  serum. 

Cultures  on  Glycerin  Bouillon. — A  Glycerin  Bouillon  of  acid 
reaction  forms  a  good  medium  for  the  growth  of  tubercle  bacilli, 
the  organisms  growing  quite  rapidly  on  its  surface.  A  wrinkled 
crust  is  formed  which  gradually  becomes  thicker  and  covered 
with  light  yellow  puffy  masses  and  folds,  while  the  bouillon  under- 
neath remains  clear. 

Resistance  to  Heat. — If  the  tubercle  bacillus  is  exposed  to 
moist  heat  of  55°  C.  for  a  period  of  six  hours  it  is  killed;  dry  heat 
is  borne  better.  According  to  SCHILL  and  FISCHER  4  it  can  be 
exposed  to  a  temperature  of  100°  C.  for  an  hour  without  being 
killed. 

Pasteurization  of  milk  is  a  question  of  marked  practical  im- 
portance. The  heating  of  milk  up  to  65-70°  C.  in  open  vessels 
is  not  sufficient  for  complete  sterilization,  because  the  bacteria 
rise  to  the  top  where  the  temperature  is  lower.  To  insure  com- 
plete pasteurization,  the  milk  has  to  be  stirred  or  treated  in 
closed  vessels.  If  the  latter  method  is  employed  good  results 
are  obtained  by  maintaining  a  temperature  of  65°  C.  for  20 
minutes. 

Effect  of  Cold. — Generally  speaking,  cold  does  not  seem  to 
have  any  effect  on  the  tubercle  bacillus  with  the  exception  that 
the  alternate  exposure  of  the  organism  to  thawing  and  freezing 
is  destructive  to  its  virulence. 

Effect  of  Moisture. — The  absence  of  moisture  in  the  culture 
tends  to  decrease  the  life  of  the  organism.  Under  ordinary  cir- 
cumstances the  culture  may  retain  its  virulence  for  six  to  eight 
months.  The  virulence  of  sputum  is  a  question  of  paramount 


28       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

importance.  A  number  of  external  conditions  influence  the 
vitality  of  the  germ,  namely,  exposure  to  light,  heat  and  air. 
Under  favorable  conditions  the  tubercle  bacilli  in  dried  sputum 
may  retain  their  vitality  for  many  months. 

Action  of  Light. — Sunlight  is  the  arch  enemy  of  tubercle 
bacillus.  KOCH  showed  that  cultures  in  thin  layers  were  sterilized 
within  a  few  minutes  when  exposed  to  strong  sunlight,  while 
diffused  daylight  required  several  days.  The  combined  effect 
of  sunlight  and  air,  without  doubt,  rapidly  destroys  the  virulence 
of  the  tuberculous  sputum,  even  the  electric  arc  light  has  been 
proven  to  have  an  injurious  effect  on  the  bacilli.  BANGS  5  of  the 
Finsen  Light  Institute,  showed  that  tuberculous  cultures  were 
sterilized  after  an  exposure  of  from  3  to  9  minutes  to  this  light. 

Water  as  a  Harbinger. — Pure  water  may  harbor  virulent 
bacilli  for  many  months  under  favorable  conditions,  but  in  nat- 
ural conditions  the  germs  are  rendered  avirulent  in  a  compar- 
atively short  time  by  the  effect  of  light  and  processes  of  decom- 
position. 

Action  of  the  Gastric  Juice. — The  Gastric  Juices  are  inimical 
to  the  growth  of  the  tubercle  bacilli  and  may  in  the  test  tube 
even  cause  their  death,  but  the  effect  in  the  human  stomach  most 
probably  does  not  play  any  r61e  on  account  of  the  varying  acid 
strength  of  the  gastric  juice  and  the  short  time  the  food  remains 
there. 

Effect  of  Antiseptics. — The  ordinary  bactericidal  agents  such 
as  mercuric  chloride,  phenol,  etc.,  have  very  little  effect  on  the 
tubercle  bacilli.  A  five  per  cent  solution  of  phenol  requires  24 
hours  to  sterilize  a  culture.  But  substances  having  solvent  ac- 
tion, such  as  combinations  of  soap  and  the  kresols,  are  very 
effective.  Lysol,  for  instance,  hi  one  per  cent  solution  will  kill 
the  bacilli  in  a  comparatively  short  time.  The  strongly  oxidizing 
agents  are  also  of  value.  Calcium  hypochlorite  is  the  disinfectant 
par  excellence  for  sputum  and  feces. 

Chemistry  of  the  Tubercle  Bacillus.— The  Bacillary  Bodies 
contain  substances  soluble  in  alcohol  and  ether  solvents,  which 
consist  of  fatty  acids,  neutral  fat  and  wax,  also  albuminous 
bodies,  carbohydrates  and  mineral  constituents.  The  amount 


ETIOLOGY  29 

of  fat  may  reach  forty  per  cent.  KLEBS  6  isolated  two  fatty 
bodies,  one  soluble  in  ether  and  one  in  benzine.  According  to 
DEYCKE,  it  is  the  neutral  fats  which  are  responsible  for  the 
acid  and  alcohol  resisting  power  of  the  bacilli,  while  the  fatty 
acids  give  them  their  specific  staining  property.  The  nucleo- 
proteids  extracted  by  WEIL  and  H.  HOFFMAN  and  identified  by 
DESCHWEINITZ  were  analyzed  by  LEVENE  and  RUPPEL  independ- 
ently, who  succeeded  in  liberating  free  nucleinic  acid.  RUPPEL  7 
further  succeeded  in  decomposing  this  acid  into  thymin  and  a 
neutral  substance  called  "  tuberculosin." 

Varieties  of  Tubercle  Bacilli. — A  great  number  of  color-fast 
bacilli  exist  in  nature.  Of  these  at  least  four  types  belonging  to 
the  tubercle  bacillus  group  are  pathogenic — namely,  the  human, 
bovine,  avian  and  piscine  types. 

THE  BACILLUS  TUBERCULOSIS  Bovis. 

Morphology. — The  bovine  bacilli  are  shorter  and  thicker 
than  the  human  type;  they  are  straighter  in  outline  and  often 
somewhat  wedge-shaped. 

Staining  Characteristics. — The  Bovine  type  has  the  same 
staining  properties  as  the  human  type,  but  as  a  rule  stains  more 
homogeneously  and  becomes  more  highly  colored. 

Culture  Characteristics. — The  bovine  bacillus  is  more  difficult 
to  cultivate,  growing  more  slowly  than  the  human  type.  Accord- 
ing to  THEOBALD  SMITH  it  produces  an  alkaline  reaction  in  broth. 

Pathogenesis. — The  main  differentiating  point  between  bovine 
and  human  tubercle  bacilli  is  the  difference  in  their  virulence 
for  animals.  The  human  type  does  not  cause  progressive  tuber- 
culosis in  the  rabbit;  in  subcutaneous  injection  a  transitory 
swelling  of  the  nearest  gland  may  be  noticed,  but  this  soon  in- 
volutes. The  bovine  type,  on  the  other  hand,  causes  a  marked 
enlargement  of  the  regional  glands  in  three  to  four  weeks;  pro- 
gressive tuberculosis  develops,  especially  in  lungs,  kidneys, 
spleen  and  liver.  The  human  type  is  nearly  non-pathogenic  for 
cattle  while  the  bovine  type  is  highly  virulent.  The  guinea-pig 
is  highly  susceptible  to  both  types,  although  it  dies  somewhat 
more  quickly  from  bovine  infection. 


30       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

THE  BACILLUS  TUBERCULOSIS  AVIUM. 

Morphology.— The  Avian  tubercle  bacillus  resembles  the 
human  type  but  fragmental  and  beaded  forms  are  more  common. 
In  staining  properties  it  does  not  differ  from  the  other  types, 
being  both  acid  and  alcohol  fast. 

Culture  Characteristics. — The  Avian  Bacillus  is  the  least 
difficult  to  cultivate.  It  grows  luxuriantly  on  all  culture  media; 
no  addition  of  glycerin  is  needed  for  its  growth.  The  culture 
has  a  moist  creamy  consistency,  thus  differing  from  the  dry 
appearance  of  the  other  types.  In  contradistinction  to  the 
human  and  bovine  types,  it  retains  its  virulence  when  growing 

at  43°  C. 

Pathogenesis. — Birds  are  the  most  susceptible  animals; 
guinea-pigs  are  quite  immune,  but  rabbits  are  easily  infected. 

THE  BACILLUS  TUBERCULOSIS  PISCIUM. 

The  Reptilian  or  Piscine  type  grows  readily  at  low  temperature 
(20°-25°  C.)-  It  is  not  infectious  to  mammals  or  birds. 

Saprophytic  Acid-fast  Bacilli. — A  number  of  saprophytic  acid- 
proof  bacilli  have  been  described  resembling  the  tubercle  bacillus 
in  morphology  and  staining.  The  most  common  are  Bacillus 
smegmatis,  Moeller's  grass  bacillus,  butter  bacillus  of  Rabin- 
owitsch  and  the  pseudo-bovine  bacillus.  They  all  grow  luxu- 
riantly on  artificial  media  and  exhibit  more  often  actinomyces- 
like  forms. 

Animal  inoculation  may  sometimes  lead  to  production  of 
nodular  lesions  resembling  the  tubercles;  but  they  are  not  caused 
by  the  pathogenetic  action  of  the  bacilli,  but  result  from  the 
foreign  body  action. 

Phylogenesis  and  Change  of  Type.— McFarland  states  that 
it  is  not  impossible  that  the  bacilli  of  human,  bovine  and  avian 
tuberculosis  are  closely  related  to  one  another  and,  together  with 
a  few  other  microorganisms  of  similar  morphology  and  staining 
peculiarities,  have  a  common  ancestry  and  are  descended  from 
the  same  original  stock. 


ETIOLOGY  31 

CHABASS  quoting  FERRAN  says  that  the  acid-fast  bacillus  of 
KOCH  is  not  the  most  liable  or  frequent  factor  in  spreading  tuber- 
culosis, because  it  is  impossible  by  means  of  this  bacillus  to  ex- 
plain the  enormous  incidence  of  tuberculosis,  also  other  prob- 
lems in  the  etiology;  the  primary  changes  are  due  to  a  group  of 
tuber culogenous,  non-acid  fast  bacteria,  which  produce  an  in- 
flammation that  can  kill  in  a  few  hours,  or  pass  into  a  chronic 
state  producing  tubercles,  the  causative  factor,  changing  into 
the  acid-fast  bacillus  of  KOCH. 

Much's  Granules. — The  significance  of  the  so-called  MUCH'S 
granules  is  not  quite  known;  MUCH  and  DEYCKE  consider  them 
the  primitive  form,  from  which  the  typical  tubercle  bacilli 
develop,  hence  playing  the  same  role  as  FERRAN'S  bacteria. 

That  a  biologic  relationship  9  exists  between  the  true  tubercle 
bacilli  and  the  non-pathogenic  type,  is  shown  by  the  experiment 
of  KRAUSE  who  demonstrated  that  extracts  of  smegma  and 
grass  bacilli  are  capable  of  producing  tuberculin  reactions;  KOCH 
also  showed  that  specific  tuberculous  agglutinating  serum  caused 
agglutination  of  grass  bacilli  and  precipitation  of  their  culture 
fluid. 

Relation  between  Human  and  Bovine  Types. — The  relation- 
ship between  the  human  and  bovine  tubercle  bacilli  is  a  very 
hotly  disputed  question.  For  a  number  of  years  after  KOCH'S 
discovery,  the  two  were  considered  to  be  identical.  In  1896, 
THEOBALD  SMITH  10  published  the  results  of  his  exhaustive 
studies  on  this  particular  point.  His  observations  form  the 
foundation  for  our  present  knowledge  of  the  differences  between 
the  two  bacilli.  KOCH  also  took  up  this  question,  and  at  the 
International  Congress  on  Tuberculosis  in  London  (1901)  ex- 
pressed his  belief  that  the  human  and  bovine  forms  of  tuberculo- 
sis were  caused  by  different  types,  if  not  different  species.  Va- 
rious writers  have  expressed  the  opinion  that  the  two  bacilli 
are  of  one  and  the  same  species,  the  apparent  differences  being 
due  to  adaptation  to  different  surroundings;  a  number  of  in- 
vestigators have  reported  successful  attempts  to  increase  the 
virulence  of  the  human  bacillus  by  passing  them  through  goats, 
(v.  BEHRING,  PEARSON,  EBER,  DE  JONG,  DAMMAN  and  MUESSEM- 


32       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

BLER)— others  report  negative  results  (KOSSEL,  WEVER,  HEUSE, 
and  THEOBALD  SMITH.) 

Change  in  Type.— CORNET  n  emphatically  denies  any  pos- 
sibility for  a  change  from  one  type  to  the  other,  charging  every 
investigator  who  has  succeeded  in  demonstrating  that  under 
certain  conditions  this  very  thing  may  take  place,  with  some 
fault  in  the  technic.  THEOBALD  SMITH,  L.  RABINOWITSCH  and 
DUVAL  12  report  the  existence  of  intermediate  forms. 

v.  BEHRING  13  rightly  calls  attention  to  the  fact  that  the 
anthrax  bacillus  can  be  changed  to  a  non-sporagenous  bacillus 
and  less  gradually  to  an  avirulent  one.  Taking  all  evidence  into 
consideration,  for  and  against,  it  must  be  admitted  that  con- 
clusive proof  is  wanting  of  an  actual  or  permanent  transformation 
of  one  type  into  another  by  the  passage  through  animals,  or  by 
culture,  but  on  the  other  hand,  the  impossibility  of  such  a  change 
is  neither  proven. 

INCIDENCE  OF  INFECTION. 

The  Human  Tubercle  Bacillus  undoubtedly  is  the  most  com- 
mon factor  in  producing  tuberculosis  in  man.  The  tubercle 
bacillus  is  commonly  referred  to  as  ubiquitous,  but  always  with 
the  reservation  that  it  does  not  multiply  outside  the  animal  body. 
But  modern  investigations  seem  to  disprove  this  idea  of  ubiquity. 
CORNET  14  showed  by  exhaustive  experiments  that  the  only 
place  where  bacilli  were  found  in  numbers  worth  mentioning  was 
in  shut-up  rooms  occupied  by  tuberculous  patients. 

The  Bovine  Type. — The  significance  of  bovine  infection  in 
man  is  an  unsettled  question.  The  most  opposed  views  have 
been  put  forth,  v.  Behring's  original  theory  that  all  tuberculosis 
is  due  to  the  bovine  infection  acquired  in  infancy  is,  at  present, 
considered  more  or  less  obsolete  by  most  authors.  The  opposite 
opinion,  that  bovine  infection  can  be  ignored,  has  had  many 
supporters.  The  exhaustive  researches  on  this  particular  point 
during  the  last  few  years  have  enabled  us  to  get  a  better  under- 
standing of  this  important  question.  The  bovine  bacillus  has 
been  found  time  and  again  to  be  the  causative  factor  of  tuber- 


ETIOLOGY  33 

culous  processes  in  man.  While  the  danger  from  this  source  has 
been  exaggerated,  it  is  now  proven  without  any  doubt  to  be  a 
distinct  menace. 

THEOBALD  SMITH,  one  of  the  first  investigators  to  differentiate 
between  the  human  and  bovine  types  of  the  bacilli  (1896)  stated 
that  bovine  tuberculosis  might,  under  certain  conditions,  be 
transmitted  to  children.  KOCH  at  the  British  Congress  on  Tuber- 
culosis (1901)  seemed  to  prove  that  transmission  of  the  bovine 
type  to  man  was  a  very  rare  occurrence  and  hence  deemed  it  not 
advisable  to  take  any  measures  against  it. 

Pulmonary  tuberculosis  in  man  is,  undoubtedly,  in  the  vast 
majority  of  cases  caused  by  the  human  type  of  bacillus;  but 
researches  have  disclosed  the  fact  that  not  a  mean  percentage 
of  glandular  tuberculosis,  especially  mesenteric  and  cervical,  is 
caused  by  the  bovine  bacillus. 

PARK  15  made  a  very  thorough  investigation  to  ascertain  the 
frequency  of  human  tuberculosis  in  New  York  City  due  to  bovine 
tuberculosis;  he  came  to  the  following  conclusion:  "Fatal  tuber- 
culosis due  to  bovine  bacillus  is  rare  in  those  over  five  years  of 
age,  but  on  the  other  hand,  infection  of  the  lymph-nodes  is  fre- 
quent, 30%  or  more  of  tuberculous  lymph-nodes  occurring  in 
children  between  five  and  sixteen  years  of  age  are  contracted 
through  bovine  bacilli."  Including  the  result  of  his  own  in- 
vestigation, which  involved  nearly  500  cases,  PARK  reports  the 
following  cases  from  the  literature: 


34       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

PARK'S  TABLE 


ADULTS 

CHILDREN 

CHILDREN 

DIAGNOSIS 

16  yrs.&  over 

5-16  yrs. 

Under  5  yrs. 

Human  Bovine 

Human  Bovine 

Human  Bovine 

Pulmonary  Tuberculosis 

778 

3 

14 

35 

I 

Tuberculous  Adenitis 

inguinal  or  axillary 

3 

4 

2 

Cervical  Tuberculosis 

36 

i 

36 

22 

IS 

24 

Abdominal  Tuberculosis 

16 

4 

8 

9 

IO 

14 

Generalized  Tuberculosis, 

alimentary  origin 

6 

i 

3 

4 

17 

IS 

Generalized  Tuberculosis, 

29 

5 

I 

74 

7 

Generalized  Tuberculosis, 

including  meninges, 

alimentary  origin 

i 

S 

10 

Generalized  Tuberculosis, 

including  meninges 

5 

10 

76 

i 

Tuberculosis  of  Bones 

and  Joints 

32 

i 

4i 

3 

27 

4 

Tuberculous  Meningitis 

i 

3 

28 

Genito-Urinary  Tuberculosis 

22 

i 

2 

Tuberculosis  of  Tonsils 

i 

Tuberculosis  of  Skin 

10 

3 

4 

6 

2 

Miscellaneous  cases 

of  Tuberculosis 

Tuberculosis  of  Mouth 

and  Cervical  Nodes 

i 

Tuberculous  sinus  or  abscess 

2 

Septic.    Latent  bacilli 

I 

TOTALS 

940 

IS 

131 

46 

292 

76 

A.  P.  MITCHELL  16  considers  the  part  played  by  the  bovine 
bacillus  in  the  causation  of  tuberculosis  in  man,  one  of  the  most 
important  public  health  questions.  In  post-mortem  examinations 
of  29  cases  under  12  years  of  age  he  isolated  cultures  from  12, 
finding  the  bovine  type  in  four,  and  the  human  in  seven  cases. 
The  bovine  infection  represented  primary  disease  of  the  mes- 
enteric  glands,  the  other  primary  disease  of  the  bronchial  glands  in 
six  cases,  one  being  uncertain.  Amongst  80  cases  of  tuberculous 
cervical  glands  the  same  investigator  found  71  cases,  i.  e.,  88% 
due  to  bovine  infection,  and  9  to  the  human  type  of  the  bacillus. 


ETIOLOGY  35 

Bovine  Type  Frequent  Cause  of  Tuberculous  Lymphadenitis. — 

In  a  recent  article  MITCHELL  16  again  emphasizes  the  importance 
of  the  bovine  bacillus  in  infection  of  the  tonsil  with  subsequent 
changes  in  the  cervical  glands.  In  106  cases  of  distinct  tuber- 
culosis of  the  cervical  glands  the  tonsils  on  microscopic  ex- 
amination were  found  to  be  tuberculous  in  38%.  Animal  inocu- 
lation in  92  cases  gave  20  positive  results,  the  bovine  type  of 
bacillus  being  isolated  in  16.  In  100  cases  of  hypertrophied 
tonsils  with  barely  palpable  cervical  glands,  the  tonsils  were, 
on  microscopic  examination,  found  to  be  tuberculous  in  9%. 
Animal  inoculation  gave  positive  results  in  all  cases,  4  of  which 
were  proven  to  be  bovine  in  type,  2  human  and  3  not  determined. 
WOODHEAD  17  reports  29  cases  of  primary  abdominal  tuber- 
culosis; of  these  14  yielded  bovine  bacilli  only,  whilst  in  two 
cases  both  types  of  bacilli  were  demonstrated  and  separated. 
Of  the  14  cases  containing  bovine  bacilli,  10  were  children  be- 
tween the  ages  of  one  and  three  years,  3  between  four  and  five 
years  and  one  eight  years  of  age.  From  these  observations  it  is 
clearly  seen  that  the  bovine  tubercle  bacillus  plays  a  very  definite 
role  in  production  of  tuberculous  lesions  during  childhood, 
especially  those  of  the  abdominal  organs  and  cervical  glands. 
Both  of  these  forms  of  tuberculosis  are  often  due  to  ingestion  of 
tuberculous  infective  material.  A  nearly  universal  diet  for 
children  is  milk;  hence  it  is  seen  what  an  important  r61e  milk 
plays  in  transferring  the  bovine  bacillus  upon  the  human  host. 

SOURCE  OF  INFECTION 

Cow's  milk  is,  without  question,  the  most  common  medium 
by  which  bovine  tuberculosis  is  transferred  to  man.  BANGS  in 
Denmark  was  the  first  investigator  to  emphasize  the  importance 
of  a  rigid  milk  inspection.  Examination  of  the  milk  supply  has 
been  made  in  a  number  of  cities,  and  it  shows  that  raw  market 
milk  of  the  cheaper  grades  in  most  cities  frequently  contains 
bovine  tubercle  bacilli.  PARK  examined  100  samples  of  milk 
in  New  York  (1908)  and  found  12%  infected;  in  1912  he  found 
6%.  In  examination  of  Edinburgh's  supply  of  milk  (406  samples) 
MITCHELL  found  20%  were  tuberculous. 


36       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

How  does  the  milk  become  infected?  The  most  common 
mode  is  by  the  presence  of  a  tuberculous  udder.  In  these  cases 
the  milk  may  contain  an  enormous  number  of  bacilli.  These 
ulcers  of  the  udder  are  sometimes  so  small  that  they  cannot  be 
noticed  with  the  naked  eye;  but  an  open  ulcer  of  the  udder  is  not 
required  to  infect  the  milk. 

The  tuberculous  cow  may  cough,  swallow  the  bacilli  and  pass 
them  with  the  feces.  Contamination  of  the  milk  may  thus  easily 
occur,  especially  on  the  average  farm  where  ideas  of  hygiene  and 
cleanliness  are  not  what  they  ought  to  be. 

Tuberculous  meat,  beef  or  pork,  most  probably  is  not  of  very 
great  consequence.  Meat,  as  a  rule,  is  quite  thoroughly  cooked 
before  it  is  consumed,  hence  if  any  bacilli  should  happen  to  be 
present  the  chances  are  that  they  would  be  killed;  on  the  other 
hand,  meat  forms  a  comparatively  small  part  in  the  diet  of 
children  who,  as  has  been  demonstrated,  are  most  susceptible 
to  bovine  infection. 

OTHER  FACTORS  HAVING  BEARING  ON  THE  ETIOLOGY 

Predisposition. — The  fatalistic  theory  of  a  specific  predis- 
position to  tuberculosis  has  had  for  centuries  a  stranglehold  upon 
the  human  mind.  Even  during  later  years  theories  have  been 
advanced  and  constitutions  described  tending  to  prove  the 
positive  existence  of  such  a  condition.  Hippocrates  described 
a  "habitus  phthisicus"  which  does  not  differ  very  much  from 
the  tuberculous  habitus  described  by  modern  authors.  But  all 
these  cases  of  predisposition  undoubtedly  represent  the  first 
stages  of  the  disease.  Modern  investigations  have  disclosed  the 
fact  that  nearly  all  human  beings  have,  or  have  had,  a  tuber- 
culous infection.  Hence,  it  would  seem  that  nearly  all  are  pre- 
disposed. It  is  consequently  irrational  to  speak  of  a  predisposi- 
tion to  tuberculosis  in  a  certain  few  when  the  greatest  majority 
of  the  human  family,  at  least  those  in  touch  with  civilization, 
have  been  proven  to  be  attacked. 

The  subsequent  development  of  the  disease  is  another  matter 
depending  upon  entirely  other  factors,  viz.  :-massiveness  of  the 


ETIOLOGY  37 

infection,  virulence  of  the  bacilli,  resistance  of  the  individual — 
not  to  be  confused  with  predisposition — age  when  attacked, 
time  of  diagnosis  and  treatment  of  the  disease.  If  we  speak  of 
predisposition  to  tuberculosis  in  the  broadest  sense  of  the  word, 
viz.: — comparing  the  effect  on  different  races,  we  may  have 
some  excuse  for  using  the  term.  But  even  here,  there  is  a  chance 
for  argument.  Many  races  were  for  a  long  time  considered 
immune  to  the  disease,  but  later  happenings  indicated  that  they 
had  not  been  exposed  before,  because  as  a  result  of  closer  con- 
tact with  civilization — hence  with  infection — they  soon  were 
ravished  by  a  severe  form  of  the  disease.  But  the  lack  of  natural 
immunity  is  quite  different  from  predisposition. 

The  fact  that  the  civilized  races  are  not  the  victims  of  such 
severe  forms  of  the  disease  proves  that  something  entirely  op- 
posed to  predisposition  exists,  viz. : — a  resistance  which  tends  to 
lessen  the  virulence  of  the  disease,  an  acquired  racial  immunity. 
Several  races  have  been  said  to  be  particularly  resistant  to  the 
disease:  the  Jewish  race  for  instance,  whose  manner  of  living, 
social  conditions,  city  life,  etc.,  have  certainly  given  this  people 
a  resistance  which,  under  ordinary  conditions,  would  prove  and 
does  prove  to  be  of  great  value.  But  look  at  the  congested  dis- 
tricts of  the  greater  cities  often  inhabited  only  by  Jews.  Is  not 
tuberculosis  common  among  them?  Consider  the  Chinese  as 
found  in  America.  The  mortality  from  tuberculosis  amongst 
them  does  not  differ  very  much  from  that  of  the  negro.  The 
resistance  of  the  ancient  Chinese  race  against  tuberculosis  gained 
from  contact  with  the  disease  for  thousands  of  years  is  not  great 
enough  to  overcome  the  depreciating  effects  of  unhygienic  living, 
excessive  labor  and  many  vices  common  amongst  so  many  of 
the  Chinese  in  this  country. 

Hereditary  Predisposition. — This  ancient  supposition,  in- 
vestigated at  a  time  when  the  real  nature  of  the  disease  was  not 
known,  still  plays  quite  an  important  r61e  according  to  some 
authors  in  propagation  of  the  disease;  the  great  mass  of  people 
believe  it,  and  the  family  of  the  tuberculous  person  regards  it 
with  horror.  The  theory  is  based  on  the  well-known  fact  that 
children  of  tuberculous  parents  develop  tuberculosis  quite  fre- 


38       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

quently.  Before  the  infectious  nature  of  the  disease  was  known 
this  theory  explained  many  more  or  less  obscure  facts. 

The  hereditary  predisposition  gave  a  perfect  explanation  why 
so  many  in  the  same  family  succumbed  to  the  disease.  But 
it  has  also  removed  the  hope  from  many  individuals  who,  under 
normal  conditions,  would  be  able  to  fight  the  affection  with 
success.  It  is  impossible  to  estimate  how  many  lives  have  been 
ended  prematurely,  on  account  of  this  fatalistic  teaching;  the 
stricken  patient  was  absolutely  convinced  that  he  did  not  have 
any  chance  whatsoever  in  the  struggle  for  life,  and  hence  fell 
an  easy  prey  to  this  illness  which,  bar  none,  requires  the  most 
optimistic  state  of  mind  for  success  in  its  treatment. 

It  is  true  that  tuberculosis  often  is  a  family  disease,  but  not 
on  account  of  any  hereditary  tendency,  but  on  account  of  the  in- 
creased opportunities  of  infection  due  to  close  contact  in  the 
ordinary  family  life.  That  this  is  true  is  proven  by  the  fact  that  if 
the  baby  is  removed  from  the  tuberculous  surroundings  and  pro- 
tected from  the  ordinary  opportunities  of  infection,  he  will  remain 
healthy  in  the  great  majority  of  instances. 

Previous  Diseases. — The  acute  infectious  diseases  certainly 
play  some  r61e  in  awakening  a  previously  dormant  tuberculous 
focus  to  activity.  We  often  have  latent  inactive  foci  hi  the 
lymphatics.  In  childhood  the  lymphatic  glands  are  very  sen- 
sitive to  tuberculous  infection.  It  is  common  to  find  tuberculosis 
following  many  of  the  acute  or  wasting  diseases  of  childhood, 
and  the  infection  seems  to  show  a  predilection  for  the  lymph- 
nodes.  Considering  the  enormous  morbidity  of  measles,  whoop- 
ing cough  and  influenza,  COPELAND  18  thinks  that  the  incidence 
of  tuberculosis,  as  a  complication  or  sequela,  is  of  relatively 
importance. 

GANGHOFNER  19  of  Prague  gives  the  following  table  to  show 
the  incidence  of  the  tuberculous  infection  in  acute  infectious 
diseases: 

Heller  of  Kiel — 714  cases  dead  from  acute  infectious 

diseases — 140  tuberculous  or  19.6% 
Councilman  of  Boston — 220  cases — 35  tuberculous,  16% 
Baginsky  of  Berlin  806  "  144  "  17.8% 

Ganghofner  of  Prague    973      "       253  "          28% 


ETIOLOGY  39 

v.  PIRQUET  has  shown  that  there  is  an  allergic  reaction 
during  the  first  stage  of  measles.  ROLLY  has  proven  that  the 
same  thing  is  true  in  pneumonia,  scarlet  fever  and  severe  con- 
stitutional diseases.  The  acute  infections  are  characterized  by 
a  marked  catarrhal  inflammation  of  the  mucous  membranes  over 
the  entire  body,  and  by  greatly  lowered  resistance,  also  attended 
with  intense  hyperemia  and  lymphatic  activity.  If  there  are 
any  latent  foci  of  tuberculosis  in  the  body  the  increased  vascular 
changes  will  cause  the  bacilli  to  penetrate  the  zones  of  infiltration 
and  settle  in  different  places  of  the  body.  The  lymph-glands  are 
the  most  likely  to  be  affected  on  account  of  their  lessened  re- 
sistance caused  by  repeated  attacks  of  infectious  diseases — 
measles,  whooping  cough,  influenza  and  catarrhal  infections. 
The  lowered  general  resistance  of  the  body  to  tuberculosis 
shown  by  the  allergic  tuberculin  reaction  gives  the  tuberculous 
infection  a  chance  to  progress. 

Nervous  System. — Changes  in  the  nervous  system  manifested 
by  instability,  as  exhibited  in  the  children  of  neurotic,  neu- 
rasthenic parents,  constitute  no  mean  par  tin  our  etiologic  picture. 
Often  nervous  affections  are  found  in  certain  families  and  are 
known  to  alternate  between  tuberculous  parent  and  offspring. 
Thus,  for  instance,  in  a  tuberculous  family  you  will  see  one  of 
the  children  dying  of  tuberculous  meningitis,  another  developing 
tuberculous  lymphadenitis,  while  the  third  may  escape  the 
diathesis  but  become  a  neurotic. 

Alcohol  is  an  important  predisposing  factor  as  exhibited  in 
the  children  of  alcoholic  parents.  They  are  weak  in  body,  sub- 
normals morally  and  mentally,  and  fall  an  easy  prey  to  tuber- 
culous infections. 

Digestive  disturbances  in  children  lower  their  resistance  and 
on  account  of  the  inflammatory  condition  of  the  intestinal  mucous 
membrane  facilitate  the  intrusion  of  the  tubercle  bacilli,  hence 
causing  infection  of  the  mesenteric  glands.  YOUNG  20  examined  a 
number  of  children  suffering  from  apparent  malnutrition  but 
with  no  sign,  symptom  or  history  of  tuberculosis.  The  v.  Pirquet 
test  gave  the  following  results: 


40       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

55  children  under  i  year,  7  positive,  12.7% 
85       "  "    i^    "   IS        "        18-2% 

93       "  "      2      "   19       "         20.4% 

Under-feeding  of  high  grade  undoubtedly  has  a  pronounced 
bearing  upon  the  resistance  to  any  disease.  But  it  is  especially 
tuberculosis  that  watches  its  chances  carefully  and  gets  a  foot- 
hold whenever  the  vigilance  of  the  defensive  mechanism  of  the 
body  is  slackened. 

Malnutrition  constitutes  one  of  the  most  important  factors 
in  exposing  the  child  to  tuberculous  infection.  These  underfed, 
poorly  nourished  children  are  especially  subject  to  frequent 
colds,  nasal  catarrh,  respiratory  tract  defects.  They  are  anaemic, 
fretful,  peevish,  selfish  and  difficult  to  manage. 

Repeated  infections  of  the  upper  air  passages,  so  common 
every  fall  and  spring,  have  a  deleterious  effect  upon  the  lym- 
phatic apparatus  of  the  neck;  the  lymphatic  glands  become  less 
and  less  capable  to  cope  with  the  infections.  If  a  few  tubercle 
bacilli  should  make  their  appearance,  the  lymphoid  tissue  would 
not  have  enough  resisting  power  to  ward  off  their  attack  and 
prevent  their  propagation  and  the  subsequent  changes. 

Disease  of  the  tonsils  and  adenoids  decreases  the  resisting 
power  of  the  organism  and  renders  these  organs  more  susceptible 
to  tuberculous  infection.  Their  r61e  in  actual  infection  will  be 
taken  up  in  a  later  chapter. 

Dental  defects  have  not  received  the  attention  they  are  en- 
titled to  hi  the  genesis  of  tuberculosis,  and  also  other  diseases. 
For  the  first  six  months  of  life,  the  mucous  membrane  of  the 
mouth  is  continuous  and  intact,  but  after  that  period  hard 
structures  pierce  through  its  external  surface,  and  continue  to 
do  so,  by  a  process  termed  eruption  of  teeth  until  adult  life. 
Under  normal  conditions  the  child  erupts  at  six  months  two 
incisor  teeth,  and  completes  the  eruption  of  twenty  teeth  before 
three  years. 

Physiologically  these  deciduous  teeth  should  not  decay,  but 
under  the  influence  of  the  child's  greater  activity,  biting  and 
chewing,  associated  with  the  pressure  from  below  of  the  per- 
manent teeth,  they  should  spread  apart,  loosen  at  their  roots, 


ETIOLOGY  41 

fall  out  and  be  immediately  replaced  with  their  permanent 
successors. 

Even  under  normal  conditions  the  functions  of  the  lymphatic 
apparatus  is  markedly  taxed  during  these  physiological  changes. 
But  how  much  more  work  is  thrown  upon  it  when  decay  of  the 
teeth  sets  in. 

Dental  caries,  the  most  common  of  all  diseases,  transform  the 
teeth  into  regular  cesspools  of  infection.  This  constant  absorp- 
tion of  toxins  from  the  dental  cavities  must  undoubtedly  set  its 
stamp  upon  the  lymphatic  glands  concerned  in  their  drainage, 
and  lower  their  resistance  in  a  marked  degree.  The  transmission 
of  the  tubercle  bacilli  will  be  discussed  in  the  chapter  dealing 
with  portals  of  entry. 

Pedley's  Views. — PEDLEY  21  says  that  the  inability  to  mas- 
ticate food  in  order  to  prepare  it  properly  for  gastric  digestion, 
the  constant  nervous  irritation  caused  by  the  exposure  of  one 
pulp-chamber  after  another,  the  accumulation  of  putrid  and  de- 
composing material  in  cavities  already  the  home  of  innumerable 
bacteria,  with  the  vitiated  secretions,  are  in  themselves  sufficient 
to  produce  in  the  growing  child  a  lowered  vitality  which  renders 
it  a  ready  prey  to  other  disorders  of  the  body. 

Environments.  The  Influence  of  Climate  and  Topography. — 
The  old  ideas  that  certain  regions  of  the  earth  were  free  from 
tuberculosis  on  account  of  some  inherent  property  and  that  some 
regions  were  especially  conducive  to  it,  are  not  longer  held.  The 
different  places  considered  to  be  immune  to  tuberculosis,  are 
now  proven  to  have  been  simply  uninfected  territory.  But  as 
BALDWIN  22  expresses  it,  "The  debilitating  heat  of  the  tropics, 
with  the  high  humidity,  and  the  depressing  effects  of  the  fogs 
and  wet  winds  of  the  Atlantic  coast,  must  only  be  contrasted 
with  the  invigorating  highlands  of  the  interior,  and  the  arid 
deserts  and  sunny  tablelands  of  the  far  west,  to  admit  that 
climate  is  a  potent  factor  in  physiological  resistance  to  tuber- 
culosis." 

The  social  conditions  undoubtedly  have  a  pronounced  bearing 
upon  the  development  of  tuberculosis  in  all  its  forms.  Tuber- 
culosis is  mainly  a  disease  of  the  poor,  the  overworked,  the  under- 


42       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

paid,  the  underfed,  although  the  more  prosperous  members  of 
society  have  to  contribute  their  share.  Unhygienic  living  con- 
ditions is  the  one  single  factor  which,  next  to  the  actual  presence 
of  the  causative  germ,  determines  the  propagation  of  this  disease. 

The  Home  an  Important  Factor.— Tuberculosis  has  often  been 
called  a  house  disease,  and  that  rightly.  It  is  the  careless  con- 
sumptive in  the  home  who  is  the  most  potent  factor  in  spreading 
this  disease.  The  tuberculous  father,  mother,  sister  or  brother, 
expectorates  indiscriminately,  is  not  overly  clean  in  his  or  her 
habits,  fondles  and  kisses  the  innocent  baby. 

The  greater  importance  of  the  droplet  infection  or  that  by 
dried  sputum  is  an  academic  question  which  in  practice  can  be 
overlooked.  They  are  both  of  marked  importance.  The  bacillus 
preserves  its  virulence  long  enough  in  both  the  dry  and  wet 
state  to  be  dangerous. 

The  tuberculous  individual  may  cough  in  the  face  of  the  child, 
or  expectorate  on  the  floor — the  baby's  playground — the  effect 
is  the  same.  The  bacilli  are  bound  to  be  introduced  into  the 
highly  susceptible  body  of  the  young  child. 

Crowded  dwellings  with  dark  rooms  in  which  the  sun  scarcely 
enters  and  where  ventilation  is  an  unheard  of  thing,  are  veritable 
breeding  places  of  tuberculosis.  Granted  one  of  these  houses  and 
an  individual  with  open  tuberculosis,  not  overly  careful,  what 
chance  have  the  children  in  that  household?  ABSOLUTELY 
NONE — they  all  become  infected.  How  many  families  live,  or 
rather  try  to  exist,  in  damp,  musty  cellar  dwellings?  Lack  of 
all  conception  of  personal  hygiene  certainly  is  responsible  for 
a  great  number  of  cases;  uncleanliness  in  dwellings  permits 
the  accumulation  of  bacteria  and  hence  increases  the  chances 
of  infection;  lack  of  care  of  the  skin  favors  the  retention  of  any 
bacteria  with  which  the  individual  has  come  in  contact;  pedic- 
ulosis, according  to  some  authors,  plays  a  definite  role  hi  pro- 
duction of  tuberculous  cervical  adenitis.  What  value  will 
ultimately  be  assigned  to  casual  infection  such  as  occurs  through 
the  agency  of  street  dust,  flies,  water  and  fomites  is  hard  to  tell; 
at  present  there  is  a  tendency  to  believe  that  direct,  intense  and 
prolonged  contact  is  necessary  for  infection. 


ETIOLOGY  43 

Schools. — The  contact  in  school  is  hardly  of  intimate  enough 
character  to  be  conducive  of  infection.  Open  tuberculosis  is 
quite  rare  in  children  and  hence  it  is  out  of  the  question  to  trans- 
mit the  disease  from  child  to  child.  The  schoolmaster  with  pro- 
ductive lesions  certainly  is  a  distinct  menace  to  the  pupils  and 
should  be  guarded  against. 

Factory. — The  unsanitary,  poorly  lighted,  scantily  heated 
and  ill- ventilated  factory  or  shop  employing  a  large  amount  of 
child-labor  certainly  plays  its  r61e  in  the  production  and  spreading 
of  this  disease.  The  report  of  the  investigation  made  by  the 
U.  S.  Commissioner  of  Labor  23  into  the  conditions  surrounding 
working  women  and  children  shows  that  of  the  employees  in  the 
cotton  textile  industry  5.2%  in  the  northern  mills,  and  20%  in 
the  southern  mills  are  children  under  sixteen.  In  North  and 
South  Carolina,  thirty  mills  employed  549  children  from  eleven 
and  one-half  to  twelve  hours  a  night  for  five  nights  in  the  week. 
The  same  report  referring  to  mortality  among  cotton  mill  op- 
eratives shows  that  the  child  who  works  in  a  cotton  mill  has  only 
half  as  good  a  chance  to  live  to  be  20  years  old  as  the  child  out- 
side the  mill,  and  the  1910  census  reports  41,000  child  operatives 
in  the  cotton  mills  of  the  country.  Among  the  cotton  mill  op- 
eratives approximately  one  of  every  two  deaths  between  fifteen 
and  forty-four  years  of  age  was  found  to  be  due  to  tuberculosis. 

THE  FREQUENCY  WITH  WHICH  TUBERCULOSIS  is  FOUND  IN 
CHILDHOOD 

At  the  present  time  there  is  a  very  strong  tendency  to  believe 
that  nearly  all  cases  of  tuberculosis  have  had  their  origin  in 
early  childhood.  Proofs  for  this  supposition  are  not  lacking.  The 
cutaneous  tuberculin  reaction,  so  rare  during  the  first  few  months 
of  life,  increases  in  frequency  with  every  year,  to  reach  its  height 
between  the  ages  of  10  and  15  years. 

Children  are  Born  Free  from  Tuberculosis. — Children  are,  on 
the  whole,  born  free  from  tuberculosis;  ten  per  cent  are  infected 
at  the  end  of  the  first  year,  and  only  ten  per  cent  free  at  sixteen 
years  of  age. 


44       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

The  following  table  gives  the  findings  of  various  investi- 
gators: 24 

Age  at  which  largest 

Number  of  children        percentage  of  positive  Percentage 

jfante  tested  reactions  are  obtained         of  reactions 

v.  Pirquet i4°7  J3~i4  93% 

Hamburger S3*  X3-I5  95% 

Hellesen 480  IO~14  46% 

Shaw&Baird....  33°  over  6  45% 

Meroz  &  Khalatoff  337  i°-*5  ?8.8% 

McNeil 54i  4-iS  45% 

Berberich 800  10-15  58.8% 

Lapage 1000  5-10  68.8% 

Arieti 38  7-«  59% 

Fishberg 692  14  83.9% 

Fishberg 588  14  75% 

Veeder  &  Johnson .  1321  10-14  44% 

Manning  &  Knott.  228  10-14  58.1% 

Rosquist 472  14-15  76.5% 

Different  Results  Obtained. — The  difference  in  results  ob- 
tained by  various  observers  cannot  be  easily  explained;  some 
authors  believe  that  the  discrepancies  must  be  attributed  to 
differences  of  technic;  but  MANNING  25  is  of  the  opinion  that  the 
peculiarities  of  climate,  sanitation  and  housing  of  the  different 
communities  are  responsible  for  the  different  results.  Undoubt- 
edly there  is  some  difference  in  the  prevalence  of  tuberculosis  in 
the  poorer  districts  of  Vienna  and  New  York,  and  the  smaller 
towns  of  Western  America. 

Observers  in  larger  cities  find  comparatively  small  difference 
between  the  frequency  of  tuberculosis  amongst  children  of 
tuberculous  and  those  of  non-tuberculous  parents.  FISHBERG'S  26 
findings  certainly  are  expressive;  the  children  in  the  tenement 
districts  of  New  York,  tuberculosis  or  no  tuberculosis  in  the 
family,  will  in  the  majority  of  cases  become  infected. 


ETIOLOGY  45 

FISHBERG'S  TABLE 
Percentage  giving  positive  reactions  among 

Children  of  tuberculous  parents  Children  of  non-tuberculous  parents 

Age             No.  of  cases  %  No.  of  cases                 % 

Under  i  yr.       33  15.15  56  10.07 

1-2  years          49  55-i°  39  33-33 

3-4                    90  68.88  80  41.25 

5-6                    95  65.26  106  50. 

7-10                 244  71.31  173  64.74 

11-14               181  74.58  134  69.40 

14                      37  83.79  20  75. 

That  the  opportunity  for  infection  is  less  in  the  smaller  town 
is  shown  by  the  findings  of  MANNING  and  KNOTT."  They  come 
to  the  conclusion  that  children  living  in  a  tuberculous  milieu 
react  in  ratio  of  about  two  to  one  of  those  living  in  an  environ- 
ment not  known  to  be  tuberculous. 

FINDINGS  OF  MANNING  AND  KNOTT 
Reactions  of  Exposed  and  Non-exposed  Children: 

Positive  v.  Pirquet  Negative  v.  Pirquet 

166  children  exposed                           84        50.6%  82            49-3% 
62          "    with  no 

known  exposure                   14        22.8%  48            77-4% 


228  98        42.9%          130  57-i% 

Tuberculosis  in  Infancy  a  Severe  Affair. — Tuberculosis  in 
early  infancy  is  a  very  severe  affair;  the  tendency  for  the  disease 
to  become  generalized  is  very  marked,  and  it  usually  results  in 
death.  BROWN  28  made  the  tuberculin  skin  test  on  650  cases  of 
infants  and  reports  the  following  findings:  of  62  infants  between 
the  age  of  one  and  three  months  13  gave  a  positive  reaction. 
They  all  died,  and  the  diagnosis  was  confirmed  by  autopsy.  Of 
102  cases  between  the  ages  of  three  and  six  months,  7  reacted 
positively,  6  of  those  died  and  the  autopsy  confirmed  the  diagno- 
sis. Forty- three  positive  reactions  were  found  amongst  217  in- 
fants between  six  and  twelve  months;  35  proved  to  be  tuber- 


46       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

culous.  Of  156  cases  between  twelve  and  seventeen  months,  37 
gave  a  positive  reaction.  Twenty  of  these  proved  to  be  tubei- 
culous  by  autopsy  or  bacillary  findings,  16  were  discharged  as 
improved  or  cured.  One  hundred  and  twelve  infants  between 
eighteen  months  and  two  years  of  age  were  examined,  24  gave  a 
positive  reaction,  15  of  which  proved  to  be  tuberculous  by  au- 
topsy or  bacillaiy  findings,  4  were  moribund  on  admission,  and 
5  were  discharged  as  improved  or  cured. 

Autopsy  Findings. — WOLLSTEIN  and  BARTLETT  29  report  the 
findings  of  1,320  autopsies  performed  at  the  Babies  Hospital  of 
the  city  of  New  York,  178  of  which  showed  tuberculous  lesions, 
i.  e.,  13.5%.  The  age  varied  from  2>£  months  to  five  years,  75% 
of  the  cases  being  under  two  years.  The  great  majority  of  the 
cases  (75%)  were  generalized  infections  with  tuberculous  lesions 
involving  the  lungs  and  bronchial  lymph-nodes,  as  the  most 
advanced. 

LTJBARCH  30  found  among  747  children  up  to  age  of  5  years, 
128  cases  of  tuberculosis,  or  17%.  ROTHE  31  verified  his  post- 
mortem examinations  on  100  children  by  inoculating  parts  of 
both  the  bronchial  and  mesenteric  glands  into  guinea-pigs  and 
gave  the  f ollowing  report : 

No.  Positive  results  in  animal  experiments 

Age         examined  No.  Percentage 

o-i  year  49  7  14.3 

1-2     "  28  9  32.14 

2-3     "  8  2  25. 

3-4  8  3  37.5 

4-5     "7  o  o 


TOTAL  100  21  21.% 

TUBERCULOUS  INFECTION  vs.  TUBERCULOUS  DISEASE 

Taking  into  consideration  the  large  number  of  children  who 
react  positively  to  the  tuberculin  test,  MORSE'S  32  distinction 
between  tuberculous  infection  and  tuberculous  disease  seems 
rather  well  taken.  He  defines  infection  as  the  state  of  being  in- 
fected and  disease  as  an  alteration  in  the  state  of  the  body  or  of 
some  of  its  organs,  interrupting  or  disturbing  the  performance 


ETIOLOGY  47 

of  the  vital  functions  and  causing  symptoms  of  some  sort.  A 
comparatively  small  proportion  of  the  children  showing  a  pos- 
itive v.  Pirquet  test  have  tuberculous  disease;  they  are,  however, 
infected.  It  is  the  reaction  of  the  tissue  to  the  infection  that  con- 
stitutes the  disease  tuberculosis;  this  is  also  known  as  clinical 
tuberculosis. 

Children  Susceptible  to  Infection. — The  figures  above  show 
that  children  are  very  susceptible  to  tuberculous  infection  and 
if  the  disease  attacks  any  other  organ  but  the  glands,  death 
usually  ensues.  Pulmonary  tuberculosis  is  nearly  universally 
fatal  in  children. 

As  has  been  shown  by  the  above  figures,  tuberculosis  increases 
in  frequency  with  each  year  during  childhood,  but  it  also  decreases 
in  fatality;  there  is  some  reason  to  believe  that  under  a  certain 
age  resistance  to  the  disease  is  not  developed.  WOLLSTEIN  and 
BARTLETT  in  their  series  of  cases  did  not  encounter  one  single 
healed  lesion,  and  attempts  at  healing,  shown  by  calcified  areas, 
were  found  only  five  times  in  the  lungs  and  13  times  in  the  lymph- 
nodes;  only  twice  in  infants  under  one  year  of  age. 

Location  of  Infection  in  Children. — Post-mortem  findings  in- 
dicate that  the  most  common  site  of  tuberculous  lesions  in  early 
infancy  is  in  the  bronchial  and  mesenteric  glands.  In  early  child- 
hood the  cervical  glands  run  a  close  third.  In  MEDINS  33  series 
of  632  tuberculous  infants  under  one  year  the  localization  was  as 
follows : 

In  lungs  only 78  cases 

In  bronchial  glands  only 17      " 

In  both  lungs  and  bronchial  glands  without  involvement  of  the  digest- 
ive tract 194 

In  intestine  and  mesenteric  glands  only 6 

In  portal  glands  and  liver  only i 

In  other  organs  only 7 

In  respiratory  and  digestive  tract 313 

Location  not  given 7 

In  GAFFEY'S  34  300  cases,  inoculation  experiments  showed  the 
bronchial  and  mesenteric  glands  were  simultaneously  involved 
in  29  cases;  bronchial  alone  in  17  cases  and  the  mesenteric  alone 
in  ii  cases. 


48       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

In  ROTHE'S  35 100  infants  under  five  years  the  respective  figures 

were  13,  5  and  3. 

WOLLSTEEN  and  BARTLETT's36  series  of  autopsies  on  178 
tuberculous  children  under  five  years  gives  the  following  dis- 
tribution: 

Lungs l6* 

Bronchial  glands l69 

Mesenteric  glands "3 

Mesenteric  glands  unaccompanied  by  bronchial  involvement .     9 

HEDREN"  performed  690  autopsies  on  children  and  found 
tuberculosis  in  47  cases  under  one  year  and  in  152  cases  over  one 
year.  He  gives  the  following  distribution : 

Children  under  one  year: 

Bronchial  lymph-glands 100     % 

Lungs 97-8% 

Spleen 82.9% 

Liver 61 . 7% 

Mesenteric  lymph-glands 57-4% 

Intestines 38-3% 

Kidneys 34-   % 

Meninges  and  brain 36.6% 

Cervical  lymph-glands 29.9% 

Heart 10.6% 

Pancreas 4-2% 

Adenoids 3-!% 

Tonsils 2.1% 

Children  over  one  year: 

Bronchial  lymph-glands 93-4% 

Lungs 9i-4% 

Spleen 68.4% 

Liver 57-8% 

Mesenteric  lymph-glands 48.   % 

Intestines 33-6% 

Meninges  and  brain 61 .8% 

Kidneys 27.6% 

Cervical  lymph-glands n .  2% 

With  regard  to  the  age  incidence  in  tuberculous  cervical  adenitis, 
FISCHER  38  who  has  collected  1,484  cases  gives  the  following  per- 
centage during  different  ages: 


ETIOLOGY  49 

FISCHER'S  TABLE 

Age  No.  of  cases  Percent 

i-  5  59  3-97 

6-10  120  8.08 

"-IS  233  15.7 

16-20  469  31.6 

21-25  282  19. 

26-30  130  8.67 

3i-35  63  7.25 

36-40  43  2-89 

41-45  25  1.68 

46-55  29  1.95 

56-65  18  i. 21 

In  the  author's  series  of  270  cases  of  tuberculous  cervical 
adenitis,  the  percentage  was  as  follows : 

Age  No.  of  cases  Per  cent 

i-5  7  2.58 

6-10  34  12.59 

11-15  142  52-59 

16-20  78  28.88 

over  20  9  3.33 

These  figures  show  that  the  frequency  of  cervical  glandular 
tuberculosis  is  most  marked  in  the  second  decade.  This  un- 
doubtedly is  dependent  upon  the  concomitant  frequency  of  de- 
cayed teeth  and  diseased  tonsils  during  the  same  period.  The 
importance  of  these  avenues  of  infection  will  be  further  discussed 
under  pathogenesis. 

THE   RELATION   BETWEEN   SCROFULOSIS   AND   TUBERCULOSIS 

The  conception  of  scrofulosis  is  not  as  yet  fully  understood. 
A  number  of  opinions  have  been  given  as  to  what  the  term  should 
include — a  number  of  theories  have  been  advanced  in  order  to 
explain  the  underlying  factors.  Several  attempts  have  been 
made  to  divide  the  truly  compact  mass  of  clinical  manifestations, 
described  under  this  term,  into  simpler  entities.  The  old  con- 
ception of  scrofulosis  is  purely  a  clinical  one,  the  principal  fea- 
tures of  which  are  the  peculiar  pasty  bloated  face,  associated 
with  inflammations  of  the  eyes,  chronic  catarrh  of  the  nasal 
cavities  with  discharge,  swollen  overlip,  facial  eczema  and  in- 


So       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

flammatory  changes  in  the  mucous  membranes,  coupled  with 
glandular  swellings. 

After  the  discovery  of  the  tubercle  bacillus,  a  marked  relation 
was  proven  to  exist  between  many  cases  of  scrofulosis,  so-called, 
and  tuberculosis.  The  bacillus  of  KOCH  was  found  in  a  number 
of  enlarged  glands  and  various  skin  lesions.  These  findings  then 
led  many  to  believe  that  scrofulosis  was  just  a  manifestation  of 
tuberculosis.  The  close  relation  between  the  two  conditions 
was  further  proven  when  it  was  shown  that  a  majority  of  chil- 
dren exhibiting  the  above  picture  gave  a  positive  tuberculin 
reaction.  The  fact  that  a  certain  number  of  these  children  gave 
a  negative  v.  Pirquet  test  seems  to  prove  that  this  condition  is 
not  always  a  result  of  tuberculous  infection.  This  opens  the  way 
for  a  more  accurate  classification  of  this  symptom  complex  as 
will  be  further  shown  in  the  chapter  on  Tuberculin  Diagnosis. 

Cornet's  Views. — If  the  old  conception  of  scrofulosis  with  its 
variety  of  manifestations  is  to  be  maintained,  CORNET'S  39  stand- 
point seems  rational.  In  his  masterly  treatise  on  scrofulosis  he 
describes  the  two  types — the  pyogenic  and  the  tuberculous,  ad- 
mitting that  the  latter  of  these  is  by  far  the  most  common.  But 
he  does  not  believe  that  the  genesis  of  this  condition  is  sufficiently 
accounted  for  by  the  intrusion  of  bacilli.  CORNET  does  not  take 
kindly  to  the  theories  of  general  diathesis  advanced  by  several 
authors,  but  believes  that  local  peripheral  peculiarities,  present 
in  youth,  are  responsible  for  the  development  of  scrofulosis. 
He  proposes  the  theory  that  a  difference  exists  in  the  permeability 
of  the  skin  and  mucous  membranes  in  youth  and  older  age  and 
amongst  different  individuals. 

The  skin  and  mucous  membrane  of  the  child  are  more  per- 
meable than  those  of  the  older  person.  Their  lymphatics  are 
larger  in  size,  their  glands  more  complex  in  development,  hence 
bacteria,  CORNET  concludes,  be  they  pus  cocci  or  tubercle  bacilli, 
can  penetrate  easier,  irritation  phenomena  be  produced  and  the 
picture  of  scrofulosis  finally  be  completed. 

This  localized  diathesis  he  calls  "embryonalism."  CORNET'S 
apparently  logical  reasoning  is  not  without  its  faults.  His 
theory  of  varying  permeability  of  the  skin  and  mucous  mem- 


ETIOLOGY  51 

brane  has  not  received  general  recognition,  nor  has  it  been  an- 
atomically proven.  Undoubtedly  it  is  a  difficult  thing  to  prove 
by  absolute  measurements,  but,  granted  that  he  is  right — which 
he  may  be — because  there  is  no  reason  why  the  stomata  in  the 
skin  and  mucous  membrane  should  not  vary  in  size  just  as  other 
structures,  and  as  CORNET  points  out,  the  variation  has  only 
to  be  so  very  minute,  why  should  the  infection  differ  so  markedly 
from  an  ordinary  case  of  pus  infection  which,  for  the  sake  of 
argument,  we  will  assume  CORNET  admits  may  occur  in  children? 

Let  us  take  the  eye;  a  pneumococcus  infection  of  the  eye  may 
be  mild  or  severe,  but  it  never  takes  on  the  characteristics  of  the 
phlyctenular  affection  associated  with  the  so-called  scrofulous 
manifestations.  It  would  seem  that  the  effect  of  the  bacterial 
invasion  upon  an  area  of  greater  permeability  would  produce  a 
more  severe  condition  than  under  ordinary  circumstances. 

That  phlyctenular  inflammation  of  the  eye  is  a  tuberculous 
affair  has  been  proven  time  and  time  again  by  the  wonderful 
success  with  tuberculin  treatment  in  these  cases.  Then  why  call 
this  a  symptom  of  scrofulosis  when  it  is  a  manifestly  tuberculous 
condition?  That  pyogenic  cocci  of  remarkably  low  virulence 
may  produce  a  disease  resembling  it  very  much  is  no  reason  why 
the  tuberculous  entity  should  be  overlooked,  and  confused  under 
the  ambiguous  term  of  scrofulosis.  The  same  is  true  in  a  more 
pronounced  degree  in  regard  to  the  lymphatic  glands. 

Some  authors  even  go  so  far  as  to  define  scrofula  as  a  synonym 
for  tuberculous  adenitis.  CORNET,  at  least,  is  consistent  and 
calls  tuberculosis  of  any  gland  in  the  body  a  manifestation  of 
scrofulosis.  But  greater  permeability  of  the  skin  and  mucous 
membrane,  or  no  greater  permeability,  tuberculous  lymph-glands 
certainly  comprise  a  distinct  clinical  entity,  be  the  bronchial, 
mesenteric,  cervical  or  axillary  glands  involved.  To  be  sure, 
there  are  some  which  are  more  or  less  difficult  to  differentiate 
from  non-tuberculous  enlargements,  but  this  is  no  reason  to 
combine  two  different  conditions  under  a  common  term. 

With  regard  to  tuberculosis  of  bones  and  joints,  CORNET  ad- 
mits that  this  affection  appears  independently  of  scrofulosis  in 
the  train  of  tuberculosis  of  other  organs;  but  still  he  speaks  of 


52       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

scrofulosis  of  the  bone,  describing  the  tuberculous  symptom 
complex.  The  old  conception  of  scrofulosis  certainly  did  in- 
clude the  tuberculous  affections  of  bones  and  joints,  but  why 
should  this  antiquated  teaching  be  perpetuated  when  there  is  no 
reason  for  its  existence?  It  does  not  simplify  matters,  but  has 
rather  complicated  them. 

CORNET  believes  that  the  bovine  type  of  the  tubercle  bacillus 
forms  a  very  considerable  source  of  scrofulous  tuberculosis, 
especially  tuberculosis  of  the  neck  and  mesenteric  glands.  In 
his  chapter  on  prognosis,  he  expresses  it  as  his  fixed  opinion  that 
a  considerable  part  of  scrofulosis,  about  one-third,  is  induced 
by  the  bovine  bacillus  and  that  this,  being  a  bacillus  of  foreign 
species,  is  the  cause  of  the  milder  course  of  this  disease,  compared 
with  the  rapid  course  of  internal  tuberculosis  in  children.  Con- 
sequently, according  to  CORNET,  33%  of  scrofulosis  is  caused  by 
bovine  infection  made  possible  by  greater  permeability  of  the 
skin  and  mucous  membranes,  and  its  comparatively  mild  course 
is  due  to  the  low  virulence  of  the  causative  germ.  Granted  this 
is  true — why  call  it  scrofulosis  and  not  infection  with  bovine 
type  of  the  tubercle  bacilli?  In  discussing  the  other  66% 
CORNET  accepts,  to  a  certain  extent,  theories  of  greater  resisting 
power  of  the  glands  as  explanation  for  the  mild  course  of  scrof- 
ulosis. 

Virchow's  Views. — VIRCHOW'S  theory  of  inflammatory  di- 
athesis, a  condition  characterized  by  constitutional  weaknesses 
of  the  skin,  mucous  membranes  and  lymphatics,  forms  the  foun- 
dation for  the  more  modern  theories  of  status  lymphaticus  and 
exudative  diathesis.  Virchow  considered  the  inflammatory 
diathesis  as  a  marked  predisposing  factor  in  the  development  of 
scrofulosis,  and  thought  it  to  be  due  to  maldevelopment  of  the 
glands  and  lymphatics,  whereby  they  were  rendered  more  vul- 
nerable to  infection. 

Escherich's  Theory.— In  developing  the  theory  of  status 
lymphaticus,  ESCHERICH  40  was  mainly  considering  the  r61e 
played  by  the  lymphatic  structures;  this  author  and  MORO  con- 
sider this  condition  not  as  a  diathesis  but  as  the  process  itself 
manifested  by  inflammatory  reactions  of  obstinate  nature. 


ETIOLOGY  53 

Scrofulosis,  according  to  their  conception,  is  due  to  a  tuberculous 
infection  developed  upon  the  underlying  foundation  of  this 
lymphatic  state. 

Czerny's  Theory. — CZERNY  41  developing  the  theory  of  exuda- 
tive diathesis  considered  the  condition  of  the  skin  and  mucous 
membrane  as  the  main  factor,  hence  the  name.  In  his  attempts 
to  establish  an  etiology,  he  differed  markedly  from  other  men. 
He  proposed  that  this  condition  called  by  him  exudative  diathesis 
was  due  to  a  disturbance  of  the  intermediary  fat  metabolism. 
A  certain  defect  in  the  body  composition  renders  the  child  unable 
to  take  care  of  the  same  amount  of  fat  as  a  healthy  child.  In  his 
conception  of  exudative  diathesis,  Czerny  includes  many  phenom- 
ena described  by  others  as  scrofulosis,  e.  g.,  blepharitis,  ecze- 
matous  skin  lesions  and  vesicular  eruptions,  hence  denying  the 
relation  between  the  scrofulous  habitus  and  tuberculous  infec- 
tion. To  prove  this,  Czerny  calls  attention  to  the  fact  that  he  is 
able  to  remove  the  scrofulous  habitus  by  proper  feeding,  re- 
ducing the  amount  of  fats.  HEUBNER  substantiates  this,  but  re- 
minds us  that  the  same  result  may  be  attained  by  tuberculin 
treatment. 

Heubner's  Views. — HEUBNER  42  considers  the  scrofulous 
symptom  complex  as  an  expression  of  an  underlying  tuberculous 
infection.  As  proof  for  this  he  gives  the  following  findings.  The 
catarrhal  condition  of  the  skin  and  mucous  membrane  is  preceded 
or  soon  followed  by  glandular  tuberculosis.  Post-mortem  findings 
indicate  that  all  children  with  so-called  scrofulous  habitus 
have  tuberculous  bronchial  glands.  Tuberculous  children  may 
suddenly  develop  scrofulosis.  Nearly  all  scrofulous  children 
show  a  positive  tuberculin  reaction. 

Salge's  Views. — SALGE'S  43  conception  of  scrofulosis  coincides 
with  that  of  Heubner's.  With  regard  to  the  more  or  less  hy- 
pothetical theories  of  various  diatheses,  Salge  believes  that  it  is 
more  to  the  point  on  account  of  the  close  connection  proven  to 
exist  between  scrofula  and  tuberculosis,  to  ascribe  even  the 
peripheral  affections  of  the  former  symptoms  complex  to  the 
latter  disease,  instead  of  to  something  else,  which  nobody  has 
seen  nor  proven. 


54       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

SALGE  also  urges  that  we  must  accustom  ourselves  to  regard 
the  scrofulous  individual  as  infected  with  tuberculosis,  which 
for  the  time  is  quiescent  and  not  dangerous,  but  is  apt  at  any 
time  to  assume  such  a  role  under  favorable  conditions;  such 
conditions  are  unhygienic  surroundings  and  malnutrition. 

Hochsinger's  Views. — HOCHSINGER  44  does  not  believe  with 
Escherich  that  the  lymphatic  hypertrophy  is  congenital  nor 
with  Czerny  that  hyperplasia  of  the  adenoid  tissue  is  due  to  an 
exudative  diathesis  caused  by  faulty  feeding,  but  rather  that  it 
is  the  result  of  repeated  infections  of  early  childhood.  Hoch- 
singer  considers  scrofulosis  a  disease  of  hygienic  neglect,  caused 
by  non-specific  infections  (pediculosis)  in  a  child  who  is  already 
tuberculous,  hence  dependent  upon  some  sort  of  interreaction 
between  pyogenic  and  tuberculous  infections.  Hochsinger  be- 
lieves that  the  picture  thus  produced  is  quite  characteristic  and 
well  limited  and  should  not,  although  it  stands  in  intimate  re- 
lationship with  tuberculous  infection,  be  confused  with  tuber- 
culosis but  be  called  scrofulosis.  This  author  also  expresses  the 
opinion  that  the  typically  tuberculous  lesions  of  skin,  joints  and 
glands  should  not  be  included  in  the  scrofulous  symptom  com- 
plex, but  be  considered  as  truly  tuberculous. 

Saltmann's  Views. — SALTMANN  45  retaining  the  old  conception 
of  scrofulosis,  considers  it  an  hereditary  tuberculosis,  not  due 
to  the  actual  presence  of  bacilli  but  rather  of  their  toxins,  which, 
passing  through  the  placenta,  poison  the  developing  organism. 
The  result  of  such  poisoning,  he  believes,  is  the  cause  of  the 
scrofulous  constitution  with  a  tendency  toward  acquiring  tuber- 
culosis. This  theory  presupposes  the  presence  of  tuberculous 
toxins  in  the  circulating  blood  of  the  pregnant  mother,  a  condi- 
tion which  is  hardly  plausible.  One  thing  that  speaks  strongly 
against  the  theory  is  the  fact  that  the  tuberculin  reaction  is 
very  rarely  positive  in  newborn  children,  hence  rendering  it 
very  improbable  that  tuberculous  toxins  are  present  in  the  body 
of  the  newborn. 

From  the  above  statements  we  realize  how  absolute  lack  of 
unity  exists  with  regard  to  scrofulosis,  both  as  to  its  etiology 
and  as  to  what  ought  to  be  comprised  in  the  symptom  complex. 


ETIOLOGY  55 

The  tendency  to  simplify  the  conception  of  this  disease  is  seen 
in  Heubner's  and  Salge's  views,  according  to  whom  scrofulosis 
is  a  peculiar  manifestation  of  tuberculosis. 

Eustace  Smith's  Views. — In  this  connection  it  is  interesting 
to  note  the  views  expressed  by  Eustace  Smith  (London)  in  his 
text-book  on  "Disease  in  Children": 46 

"Scrofula  or  struma,  described  as  a  widespread  constitutional 
hereditary,  obstinate  and  although  allied  to  and  often  con- 
joined with  tuberculous  manifestations,  a  perfectly  distinct  and 
separate  entity,  has  until  recent  times  occupied  a  prominent  place 
amongst  the  diseases  of  early  life.  More  modern  views,  however, 
regard  the  condition  as  merely  a  variety  of  the  tuberculous  in- 
fections which  is  strictly  localized  and  runs  a  slow  course;  and 
although,  like  the  acute  variety  it  may  involve  organs  of  vital 
importance  to  the  economy,  affords  more  space  for  treatment, 
and  is  more  responsive  to  remedial  measures  than  the  rapid 
generalized  form  which  never  spares,  but  hurries  on  relentlessly 
to  its  close. 

It  is  now  held  that  whether  the  complaint  move  quickly  or 
slowly,  it  owes  its  origin  to  one  definite  infecting  agent,  the  tu- 
bercle bacillus;  and  it  is  presumable  that  the  precise  shape  the 
disease  will  take,  is  dependent  upon  the  particular  standard  of 
virulence  of  the  organism  and  the  more  or  less  congenial  soil 
in  which  its  work  is  carried  on.  The  strumous  disposition  was 
understood  to  show  itself,  especially  in  glandular  enlargements, 
caseation  and  softening,  chronic  erosions  and  suppurations  of 
bone,  obstinate  ulcerations  of  the  skin,  and  other  such  slowly 
advancing  lesions;  but  these  changes  are  now  recognized  as  local 
tuberculous  infections  due  to  the  entrance  into  the  body  of  the 
special  bacillus." 

The  American  ideas  on  scrofulosis  vary  markedly.  HOLT  47 
in  his  text-book  on  "Diseases  in  Infancy  and  Childhood"  remarks 
in  discussing  the  subject  of  lymphatic  diathesis  with  its  tendency 
to  swellings  and  hyperplasia  of  the  lymphatic  structures,  that 
this  was  formerly  classed  as  one  of  the  manifestations  of  scrofula, 
or  struma,  and  that  the  proof  that  most  of  the  manifestations, 
once  called  scrofulous,  are  really  forms  of  tuberculosis,  makes  it 


56       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

undesirable  to  use  that  term  to  designate  the  condition  under 
discussion.  When  treating  the  subject  of  tuberculous  adenitis, 
HOLT  gives  it  the  synonym  scrofula;  hence  being  absolutely 
opposed  in  his  views  to  those  of  BALDWIN  *  who  says  that  the 
much  disputed  term,  scrofula,  deserves  retention  only  when 
applied  to  chronic  non-tuberculous  enlargements  of  the  lymph- 
nodes,  and  to  constitutional  weakness  of  the  skin  and  lymphatic 
apparatus  (inflammatory  diathesis)  described  by  Virchow. 

The  author  urges  that  the  name  scrofula  be  discontinued,  thus 
eliminating  the  confusion  which  has  existed  because  of  the  in- 
clusion of  several  conditions  under  this  term.  Exudation  or 
inflammatory  diathesis  is  a  distinct  condition  in  itself  and  when 
found  with  tuberculous  adenitis  it  has  undoubtedly  played  the 
part  of  a  predisposing  factor.  But  the  tuberculous  adenitis 
should  be  recognized  as  tuberculous  and  treated  as  such.  In  my 
experience  I  have  found  that  the  vast  majority  of  chronic  gland- 
ular enlargements,  excluding  such  conditions  as  Hodgkin's 
disease  and  syphilis,  were  tuberculous  in  origin  rather  than  due 
to  simple  infection. 

From  this  discussion  it  seems  apparent  that  the  old  conception 
of  scrofulosis,  clinical  as  it  was,  included  a  variety  of  manifesta- 
tions which  etiologically  did  not  belong  to  each  other.  The  con- 
ditions described  as  inflammatory  diathesis,  lymphatism,  lym- 
phatic diathesis,  exudative  diathesis  undoubtedly  have  something 
in  common.  It  may  be  some  fundamental  disturbance  in  the 
lymphatic  apparatus,  or  it  may  be  some  abnormal  state  in  the 
chemical  composition,  or  metabolic  changes  of  the  organism 
which  are  responsible  for  the  same,  the  fact  remains.  At  present 
it  stands  in  no  relation  to  scrofulosis  so-called,  with  the  exception 
that  the  general  resistance  may  be  lowered  and  hence  render 
the  child  an  easier  victim  to  infection.  That  scrofulosis  in  some 
way  was  dependent  upon  a  tuberculous  infection  has  been  the 
opinion  of  most  authors.  The  so-called  scrofulous  glands  have 
been  proven  to  be  tuberculous,  if  we  exclude  CORNET'S  pyogenic 
variety,  but  even  if  the  differentiation  between  these  two  con- 
ditions is  difficult,  their  being  different  entities  cannot  be  denied, 
then  why  include  them  under  the  same  name?  The  individuality 


ETIOLOGY  57 

of  the  phlyctenular  eye  lesions,  lupus,  bone  and  joint  lesions,  have 
already  been  discussed.  Hence  it  seems  advisable  to  discontinue 
the  use  of  the  term  scrofulosis  and  replace  it  with  tuberculosis 
when  the  condition  is  tuberculous,  pyogenic  infection  when  pus 
cocci  are  the  cause,  or  a  manifestation  of  exudative  or  lymphatic 
diathesis  when  no  more  definite  etiological  factor  can  be  deter- 
mined. 


CHAPTER  V 
PATHOLOGY 

PATHOGENESIS 

In  discussing  the  pathogenesis  of  tuberculosis,  we  are  entering 
upon  a  subject  which,  during  recent  years,  has  received  marked 
attention.  In  spite  of  the  enormous  amount  of  study  and  in- 
vestigation, opinions  are  still  divided  as  to  the  most  common 
modes  of  infection. 

Modes  of  Infection. — That  infection  occurs  in  childhood, 
seems  to  be  nearly  universally  accepted,  and  also  that  the  lym- 
phatic apparatus  is  most  commonly  affected — but  opinions  as  to 
the  avenues  of  infection  differ  markedly,  v.  BAUMGARTEN  is 
a  strong  believer  in  the  congenital  transmission  of  the  disease, 
v.  BEHRING  and  CALMETTE  in  the  enterogenous  mode  of  in- 
fection, but  the  great  majority  of  authors  and  investigators  hold 
to  the  bronchogenous  mode  of  infection.  Experimental  and 
clinical  proof  exist  that  infection  may  take  place  through  any 
of  these  routes,  but  the  comparative  frequency  of  each  one  is 
the  difficult  thing  to  estimate. 

Infection  Through  Infected  Ovum  or  Semen.  Congenital 
Transmission. — A  number  of  experiments  have  been  made  in 
order  to  ascertain  the  possibility  of  such  an  infection.  The 
majority  of  investigators  have  had  negative  results.  A  few 
have  succeeded  in  finding  the  bacilli  in  embryo  after  infection 
of  the  seminal  fluid,  but  these  experiments  were  made  under 
conditions  far  removed  from  those  existing  in  nature.  Hence, 
we  must  agree  with  CALMETTE  l  that  no  absolute  proofs  exist 
that  the  father  can  directly  transmit  the  infection. 

Direct  hereditary  transmission  from  the  mother  may  be  pos- 
sible, but,  if  so,  it  is  very  rare  because  as  VIRCHOW  2  has  observed, 
an  ovum  infected  with  tubercle  bacilli  loses  its  germinative 
properties  and  does  not  mature. 


PATHOLOGY  59 

Infection  through  the  Placenta. — The  passage  of  tubercle 
bacilli  through  the  intact  placental  tissue  is  still  a  disputed  ques- 
tion. CORNET  3  considers  the  normal  placenta  as  an  impenetrable 
filter  to  corpuscular  elements  and  bacteria,  but  believes  that  in- 
fectious diseases,  accompanied  by  high  fever,  may  produce 
epithelial  defects  which  render  the  passage  of  the  bacteria  into 
the  fcetal  organism  possible.  The  same  author  also  makes  the 
statement,  that  in  case  of  a  tuberculous  mother,  such  a  passage 
is  apparently  only  possible,  if  a  tuberculous  focus  is  located  in 
the  placenta  itself.  This  restriction  does  not  seem  logical  because 
if  the  possibility  of  the  discontinuity  of  the  placental  lining  is  to 
be  accepted,  the  recent  discovery  of  tubercle  bacilli  in  the  cir- 
culating blood  of  tuberculous  patients  would  make  it  possible 
for  them  to  pass  without  the  presence  of  any  actual  lesion. 

The  placental  lining  undoubtedly  is  one  of  the  most  impen- 
etrable structures  of  the  human  organism.  It  does  not  permit 
the  passage  of  any  of  the  corpuscular  elements  of  the  blood.  The 
virus  of  smallpox  may  pass,  as  proven  by  the  fact  that  children 
have  been  born  with  signs  of  the  disease.  But  an  analogy  from 
this  cannot  be  drawn  as  to  tuberculous  infection.  The  causative 
agent  of  the  former  is  unknown,  while  the  latter  disease  is  caused 
by  quite  an  appreciable  organism. 

Congenital  Infection  Rare. — The  comparatively  few  cases  of 
authentic  congenital  infection  on  record,  have  nearly  all  been 
associated  with  tuberculous  disease  of  the  placenta.  This  is, 
without  a  doubt,  the  most  common  method  of  parental  infection 
and  does  not  require  a  hypothetical  supposition  of  discontinuity 
between  the  individual  cells  of  the  placental  lining. 

A  tuberculous  disease  of  the  placenta  may  cause  ulceration 
of  the  vessels  with  subsequent  dispersal  of  the  bacilli  in  the  fcetal 
organism,  or  tubercles  in  the  placenta  may  be  broken  up  at  birth, 
and  the  particles  thus  enter  the  portal  vessels. 

HARBITZ  4  considers  infection  before  birth  extremely  rare  and 
believes  that  if  a  child  of  one  to  three  months  has  lived  even  for 
a  short  time  in  a  tuberculous  environment,  no  conclusion  can  be 
drawn  as  to  whether  the  infection  occurred  before  or  after  birth. 

The  rarity  of  congenital  transmission  of  tuberculosis  is  seen 


60        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

by  the  fact  that  the  extended  researches  in  the  literature  by  such 
men  as  HARBITZ  and  CORNET  resulted  only  in  the  rinding  of  20 
to  30  authenticated  cases.  HARBITZ  5  collected  20,  CORNET  6 
26,  and  SCHLUETER  7  20  cases  respectively.  The  rarity  of  the 
condition  is  illustrated  by  MEDIN'S  8  series  of  7,630  autopsies  of 
infants  under  one  year  with  623  cases  of  tuberculosis  among 
which  only  one  would  lead  to  suspicion  of  being  of  congenital 
origin. 

v.  Baumgarten's  Views  not  Supported. — v.  Baumgarten  is 
one  of  the  few  men  who  places  marked  importance  on  the  con- 
genital transmission  of  this  disease;  he  bases  his  theory  on  the 
experiments  of  FRIEDMAN  9  who  found  in  animals  bacilli  mixed 
with  the  sperm,  which  was  thus  transferred  to  the  foetus  and 
later  into  the  different  organs,  while  the  mother  remained  free 
from  tuberculosis.  The  same  observer  also  has  found  an  in- 
fected ovum  within  the  ovary  from  a  case  of  maternal  tubercu- 
losis. 

But  to  base  such  a  far-reaching  theory  upon  the  experiments 
of  a  single  observer  seems  rather  irrational.  Many  other  men 
have  failed  to  confirm  them.  But  v.  Baumgarten  also  lays  stress 
on  placental  transmission  and  believes  that  it  is  in  the  early 
stages  of  placental  disease  before  the  lesions  are  easily  recognized 
that  transmission  of  the  bacillus  takes  place.  This  author  then 
explains  the  further  course  of  the  disease  by  a  theory  of  latency 
and  insusceptibility  of  the  infant  tissues  to  the  formation  of  the 
tubercle,  owing  to  their  great  activity  hi  growth. 

But  the  acute  course  of  infant  tuberculosis  in  general  speaks 
against  this  supposition,  also  the  very  rare  occurrence  of  a  pos- 
itive tuberculin  test  in  newborn  children.  The  earliest  ever 
recorded  is  that  of  ZARFL,IQ  who  reported  a  positive  v.  Pirquet 
test  in  a  17  days'  old  child. 

BRONCHOGENOUS  INFECTION 

The  great  frequency  of  involvement  of  the  Bronchial  Glands 
speaks  for  the  importance  of  the  aerogenous  infection.  CAMBY 
in  a  series  of  569  cases  of  tuberculosis  found  the  bronchial  glands 


PATHOLOGY  61 

involved  in  all;  HAMBURGER  and  LENKE  found  the  same  condi- 
tion in  no  cases,  HAUSHALTER  and  FRUHINSHOLZ  in  74  out  of 
78  infants  dying  of  acute  tuberculosis,  or  tuberculous  meningitis.11 
Modern  investigations  seem  to  prove  that  in  the  great  majority 
of  cases  of  bronchial  gland  tuberculosis,  the  primary  lesion  is  to 
be  found  in  the  lung.  HEDREN  12  in  his  series  of  690  autopsies 
on  children  found  199  cases  of  tuberculosis,  of  these  47  were 
infants  under  one  year,  and  152  were  over  one  year.  The  47 
infants  had  the  bronchial  glands  involved  in  100%,  and  the  lungs 
in  98%  of  the  cases;  the  older  children  had  the  bronchial  glands 
involved  in  93.4%  and  the  lungs  in  91.4%.  HEDREN  places  great 
importance  upon  the  fact  that  in  nearly  all  of  his  cases  the  step- 
like  progress  from  the  portal  of  entry  could  be  established  and 
remarks  that  the  few  exceptions  probably  were  only  apparent. 
GHON  13  in  his  series  of  184  autopsies  on  tuberculous  children 
showed,  by  very  scrupulous  examination  of  the  lungs,  that  the 
bronchial  gland  lesions  were  accompanied  by  older  pulmonary 
lesions.  PARROTT  14  tried  to  prove  that  there  does  not  exist  any 
"tracheo-bronchial"  adenopathy  which  is  not  of  pulmonary 
origin:  "Every  time  a  bronchial  gland  is  the  seat  of  a  tuberculous 
lesion,  there  is  a  tuberculous  lesion  in  the  lung."  In  MEDIN'S 
series  of  623  autopsies  of  tuberculous  infants  under  one  year, 
98%  showed  primary  involvement  of  lungs  and  bronchial  glands. 

From  these  facts  it  would  seem  that  the  aerogenous  route  is 
mostly  concerned  in  production  of  bronchial  gland  tuberculosis 
although  the  arguments  of  v.  BEHRING  and  CALMETTE,  and 
others  are  not  to  be  lightly  thrown  away. 

Bronchial  Gland  Infection  May  be  Primary. — Although 
GHON'S  and  HEDREN'S  findings  seem  to  indicate  that  a  pulmo- 
nary lesion  is  always  present  in  case  of  hilus  tuberculosis,  many 
investigators  believe  that  the  tubercle  bacilli  are  able  to  pen- 
etrate the  pulmonary  epithelial  lining  without  producing  any 
change  and  thus  primarily  attack  the  bronchial  glands  where 
they  are  retained. 

The  bacilli  enter  with  the  inspired  air,  either  in  the  form  of 
dust  or  droplets  and  lodge  on  the  mucous  membrane  of  the 
bronchioles  or  pulmonary  alveoli.  A  local  process  may  set  up 


62       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

with  subsequent,  secondary  involvement  of  the  bronchial  glands, 
or  the  bacilli  may  pass  the  epithelial  lining,  enter  the  lymph- 
stream  and  be  propelled  to  the  pulmonary  or  broncho-pulmonary 
glands.  WOLLSTEIN  and  BARTLETT  15  hold  this  latter  theory 
far  more  tenable;  in  their  series  of  178  cases  of  tuberculosis,  14 
existed  without  any  pulmonary  lesion,  but  with  involvement 
of  the  bronchial  glands.  HEDREN  and  GHON  consider  the  pri- 
mary lesion  in  the  lung  overlooked  in  these  cases.  But  whatever 
the  case  may  be,  the  bronchial  glands  certainly  have  been  shown 
to  be  the  true  center  of  infantile  tuberculosis,  from  which  the 
disease  may  spread  in  various  ways. 

ENTEROGENOUS  MODE  OF  INFECTION 

Mechanism  of  Intestinal  Absorption. — The  intestinal  or  al- 
imentary infection  undoubtedly  plays  an  important  part  in 
children,  especially  in  infants.  This  is  proven  by  the  great 
number  of  primary  infections  of  the  mesenteric  glands,  which 
have  been  demonstrated  by  numerous  investigators.  Without 
accepting  the  radical  views  of  v.  BEHRING  and  CALMETTE  who 
contend  that  the  majority  of  the  cases  of  tuberculosis  are  caused 
by  enterogenous  infection,  we  will  consider  the  mechanism  of 
intestinal  absorption  of  tubercle  bacilli  as  put  forth  by  CAL- 
METTE.16  In  the  lower  animals,  which  possess  a  digestive  sac, 
the  cells  of  the  endoderm  send  out  toward  the  interior  of  the 
cavity  pseudopods  resembling  those  of  the  amoeba  and  which 
engulf  solid  particles  of  food.  The  enormous  absorbing  surface 
of  the  digestive  canal  in  higher  animals  is  lined  nearly  throughout 
with  similar  cells  having  the  same  properties.  They  line  the 
small  and  large  intestines.  We  know  that  during  the  process  of 
digestion,  divers  protein  substances,  fatty  acids  and  glycerin, 
solid  particles  and  bacteria  are  constantly  entering  the  intestinal 
villi.  This  process  is  realized  by  the  intervention  of  migratory 
cells,  which  penetrate  the  cylindrical  cells  of  the  intestinal 
epithelium.  This  process  is  especially  intense  in  Peyers  patches. 
When  the  microorganism  carried  by  the  leucocyte,  has  pen- 
etrated into  a  lacteal  vessel,  it  follows  the  current  of  lymph 


PATHOLOGY  63 

towards  the  nearest  lymph-gland,  the  mesenteric.  In  the  glands 
the  lymph-current  is  markedly  slowed  down,  due  to  their  peculiar 
anatomy.  If  the  bacilli  are  numerous  and  virulent,  or  if  they 
have  had  time  to  multiply,  a  typical  glandular  tuberculosis  is 
produced. 

Glands  Act  as  Filters. — In  the  young,  the  glands  act  as  nearly 
perfect  filters,  and  thus  retain  the  germs,  especially  in  case  of 
massive  infection.  A  tuberculous  lesion  is  soon  produced  which 
becomes  caseous  and  distributes  the  microorganisms  in  the 
different  lymphatics  and  blood-stream. 

But  if  the  infecting  bacilli  were  less  numerous  or  less  virulent, 
the  leucocytes  which  had  engulfed  them  would  remain  uninjured, 
conserve  their  mobility  and  continue  their  migration  in  the 
lymphatic  or  blood- vascular  network  of  the  different  organs  until 
they  lose  their  vitality.  In  older  animals  the  lymph-glands  are 
of  looser  texture,  and  often  more  permeable  than  in  the  young; 
the  bacilli  always  engulfed  by  the  leucocytes  are  carried  with 
the  lymph  of  the  thoracic  duct  into  the  blood  of  the  right  heart 
and  distributed  in  the  pulmonary  capillaries.  The  leucocytes 
having  lost  more  or  less  of  their  vitality,  are  caught  acting  as 
emboli.  The  tubercle  bacilli  contained  in  these  leucocytes, 
produce  the  typical  changes. 

The  Intestinal  Mucosa  is  Permeable. — Experiments,  demon- 
strating the  passage  of  tubercle  bacilli  through  the  healthy  in- 
testinal mucous  membrane,  have  been  performed  by  various 
investigators.  CHAVEAU  and  DOBROKLOWSKI  17  were  amongst 
the  first  to  insist  upon  the  ease  with  which  the  tuberculous  virus 
traversed  the  healthy  epithelial  lining  without  causing  any 
apparent  lesion.  That  bacteria  of  various  kinds  passed  the  in- 
testinal mucous  membrane,  especially  during  digestion  of  fatty 
material,  was  proven  by  DESOURBY  and  PORCHER  17  who  re- 
covered the  bacteria  in  the  chyle  and  blood  several  hours  later. 

Infection  by  Direct  Inoculation. — RAVENEL,  v.  BEHRING  and 
ROEMER,  BISANTI  and  PANISSET,  FICKER,  OBERWORTH  and 
L.  RABINOWITSCH  17  have  found  that  following  an  infectious  meal 
not  only  the  lymph  but  also  the  blood  frequently  contained  the 
tubercle  bacilli.  SCHLOSSMAN,  ENGEL,  ORTH  and  RABINO- 


64       TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

WITSCH  17  have  demonstrated  after  animals  have  been  infected 
by  direct  inoculation  into  the  stomach,  through  an  abdominal 
incision,  that  the  lungs  of  these  animals  six  hours  after  inocula- 
tion contained  virus  capable  of  infecting  other  animals. 

L.  Findley's  Experiment. — Findley  18  performed  a  series  of  ex- 
periments to  ascertain  what  part  the  intestines  play  as  a  portal  of 
entry  for  the  tubercle  bacillus.  He  suspended  cultures  of  bovine 
and  human  bacilli  in  oil,  enclosed  them  in  gelatine  capsules  which 
he  introduced  through  a  stomach  tube  into  the  stomachs  of 
healthy  rabbits  and  rabbits  which  had  recently  suffered  from 
intestinal  catarrh.  Findley  draws  the  following  conclusions  from 
his  experiments : 

Healthy  rabbits  can  be  infected  by  ingestion  of  large  amounts 
of  bovine  tubercle  bacilli. 

The  bacilli  can  pass  through  apparently  intact  intestinal 
mucous  membrane  and  reach  the  mesenteric  glands  within  a 
period  of  six  days. 

When  infection  occurs  the  intestine  is  invariably  the  seat  of 
the  lesions  and  thus  tuberculosis  of  any  organ  other  than  the 
intestine  is  always  a  secondary  infection  when  the  bacilli  have 
entered  by  the  intestinal  route. 

Catarrh  of  the  intestines  does  not  favor  the  passage  of  tubercle 
bacilli  through  the  wall,  but  allows  of  a  more  constant  and  wide- 
spread infection  and  in  this  way  facilitates  dissemination. 
Healthy  rabbits  apparently  cannot  be  infected  by  the  ingestion 
of  large  amounts  of  the  human  tubercle  bacilli.  Rabbits  just 
recovered  from  intestinal  catarrh  develop  tuberculosis  after  the 
ingestion  of  human  tubercle  bacilli.  With  the  human  organism, 
a  local  lesion,  though  always  present,  may  be  slight  in  comparison 
with  the  diseased  foci  in  the  mesenteric  glands. 

Walsham's  Views. — WALSHAM  19  in  his  work  on  the  channels 
of  infection  in  tuberculosis  comes  to  the  conclusion  that  the 
mesenteric  glands  may  be  found  to  be  tuberculous  without  there 
being  any  discoverable  lesion  in  the  intestine,  and  believes  that 
the  explanation  must  be  accepted,  that  the  bacilli  are  carried  by 
the  leucocytes,  along  the  lymph-channels  to  the  heart  and  lung. 

Objections  to  the  Intestinal  Routes  of  Infection. — v.  BEHR- 


PATHOLOGY  65 

ING'S  and  CALMETTE'S  contention  that  the  great  majority  of 
cases  of  tuberculosis  are  spread  by  the  intestinal  mode  of  infection 
is  hotly  contested  by  the  majority  of  investigators. 

v.  PIRQUET  20  believes  that  the  enterogenous  infection  has 
been  much  overestimated.  He  considers  intestinal  tuberculous 
invasion  in  infants  very  common  but,  as  a  rule,  secondary  and 
due  to  the  deglutition  of  tuberculous  mucus,  which  comes  from 
the  lungs. 

Intestinal  Tract  not  Susceptible  to  Infection. — CORNET  21  is 
of  the  opinion  that  the  intestinal  tract,  of  all  organs  of  the  body, 
is  the  least  accessible  to  tuberculous  infection,  not  on  account  of 
any  insusceptibility  of  its  mucous  membrane,  but  rather  on  ac- 
count of  the  quick  passage  of  the  infected  material  which  does 
not  allow  the  bacilli  to  get  a  firm  hold,  or  to  settle,  and  also  on 
account  of  the  mixing  with  the  intestinal  contents. 

COBBET  22  does  not  believe  that  the  experiments  of  VANSTEEN- 
BERCHE  and  GRYSEZ,  who  found  anthracosis  of  the  lungs  after 
feeding  guinea-pigs  india  ink  and  carbon,  were  conclusive.  He 
considers  the  anthracosis  as  a  natural  condition  of  the  city-bred 
pigs.  COBBET  failed  to  verify  the  experiments  on  country-bred 
guinea-pigs. 

One  of  the  most  forcible  objections  against  the  importance  of 
intestinal  infection  is  that  brought  forth  by  CHAUSSE",  FLUGGE 
and  FiNDEL.23  The  latter  showed  that  the  number  of  bacilli 
required  to  produce  infection  of  the  alimentary  tract  was  very 
much  larger  than  that  to  cause  infection  by  inhalation.  After 
several  experiments  he  concluded  that  the  minimum  fatal  dose 
in  ingestion  is  about  6  tunes  greater  than  the  minimum  fatal  dose 
in  inhalation.  CALMETTE  does  not  believe  that  this  objection  is 
tenable,  because  nothing  proves  that  one  virulent  bacillus  ab- 
sorbed in  the  intestine  is  sufficient  to  produce  a  tuberculous 
lesion. 

Frequency  of  Intestinal  Infection. — The  reports  on  frequency 
of  primary  intestinal  infection  vary  markedly  in  different  coun- 
tries. European  investigators  in  general  find  a  comparatively 
low  frequency.  ALBRECHT  in  examining  1,080  cases  found  only 
seven  primary  intestinal  infections;  GHON  24  examining  180  odd 


66        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

cases  found  three;  v.  HAUSEMANN  25  twenty-five  in  10,000  au- 
topsies; HUNTER  thirteen  cases  amongst  5,124;  BIEDERT  2S  six- 
teen amongst  3,104  children.  MEDIN  in  his  series  of  623 
tuberculous  infants  under  one  year,  found  primary  intestinal 
tuberculosis  hi  two  per  cent  of  the  cases  and  hence  considers  it 
of  little  importance  in  infants.  HEDREN  26  found  eleven  cases  of 
undisputable  deglutition  tuberculosis  amongst  199  tuberculous 
children  and  concludes  that  although  the  condition  is  compara- 
tively rare,  its  importance  should  not  be  overlooked.  BOVAIRD  ** 
of  New  York  refers  to  1,161  post-mortem  examinations  of  tu- 
berculous children  among  which  he  found  2.05%  suffering  from 
primary  intestinal  tuberculosis. 

GAFFNEY  and  ROTHE  28  examined  400  cases  by  inoculating 
parts  of  bronchial  and  mesenteric  glands  into  guinea-pigs. 
They  found  78  positive  cases  —  19.5%.  In  42  cases  both  groups 
were  involved  —  54%,  in  14  cases  the  mesenteric  glands  only  were 
involved  —  18%,  while  the  bronchial  glands  only  were  involved 
in  22  cases  —  28%.  WOLLSTEIN  and  BARTLETT  29  of  New  York 
in  their  series  of  1,320  autopsies  with  178  cases  of  tuberculosis 
found  primary  intestinal  lesions  in  9.5%.  W.  H.  PARK  30  in  his 
collected  series  of  1,500  cases  found  abdominal  tuberculosis  or 
generalized  tuberculosis  of  alimentary  origin  in  107  cases  —  7.13%. 
COUNCILMAN  of  Boston  found  37%  primary  intestinal  lesions. 
HELLER  of  Kiel  37.8%,  BEITZKE  16  —  20%,  and  PRICE-  JONES 


Bovine  Bacilli,  Evidence  of  Primary  Alimentary  Infection.  — 
One  of  the  best  criterions  for  primary  infection  of  the  alimentary 
tract  is  the  actual  presence  of  bovine  infection.  MITCHELL  32 
in  eight  cases  of  abdominal  tuberculosis  in  children  under  twelve 
years  of  age,  found  the  bovine  type  of  tubercle  bacillus  seven 
times  and  the  human  type  once;  all  these  children  had  been  fed 
on  raw  cow's  milk.  WOODHEAD  33  believes  that  a  considerable 
proportion  of  cases  of  tuberculosis  of  the  alimentary  canal  and 
of  the  adjacent  lymph-glands  is  the  result  of  bovine  infection. 
Even  CORNET  admits  that  small  as  the  danger  is  in  individual 
cases,  the  multiplicity  of  opportunities  gives  it  considerable 
importance  for  children. 


PATHOLOGY  67 

Secondary  infection  of  the  alimentary  tract  is  much  more 
common  than  the  primary.  It  is  then  due  to  swallowing  tuber- 
culous mucus  which  comes  from  the  lungs.  It  occurs  especially 
in  the  later  stages  of  the  disease  and  results  often  in  marked 
involvement  of  the  intestinal  wall  with  subsequent  changes  in 
the  mesenteric  glands. 

INFECTION  OF  THE  EXTERNAL  LYMPH- GLANDS 

Of  the  external  lymph-glands  the  cervical  are  the  ones  most 
often  affected  with  tuberculosis;  the  following  tables  by  BALMANN 
and  WOHLGEMUTH  34  give  us  a  conception  of  the  relative  fre- 
quency of  the  involvement  of  the  different  glands: 

Balmann  Wohlgemuth 

Neck  and  Occipital  Glands  81     %  93     % 

Axillary                          "  6     %  2.78% 

Inguinal  7     %  °-93% 

Ulner  5     %  0.23% 

Popliteal  0.7%  0.23% 

In  front  and  behind  ear  -  %  2.9% 

Cervical  Glands. — The  greater  preponderance  of  cervical 
gland  involvement  is  undoubtedly  due  to  greater  opportunities 
for  infection.  Their  area  of  drainage  is  most  commonly  exposed, 
the  upper  respiratory  and  digestive  passages  receiving  the  brunt 
of  the  attack,  whether  the  infection  is  conveyed  by  the  aerog- 
enous  route,  or  by  food  or  drink. 

Portals  of  Entry.  Palatine  Tonsils. — The  tonsils  and  the 
adjacent  area  are  drained  by  the  superior  deep  cervical  glands, 
and  according  to  WOOD,  especially  by  the  ones  lying  under  the 
anterior  border  of  the  Sterno-cleido-mastoid  muscle,  just  behind 
the  angle  of  the  mandible.  These  glands  form  part  of  the  mesial 
group  of  the  superior  deep  cervical  glands,  which  group  is  usually 
the  one  most  commonly  affected.  MOST  considers  infection  of 
the  palatine  tonsil  and  its  vicinity,  of  the  greatest  etiological 
importance. 

Waldeyer's  Ring,  The  First  Line  of  Defense. — The  situation  of 
the  tonsil  is  such  that  any  bacilli  entering  the  mouth  and  being 


68        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

swallowed,  pass  over  its  surface  and  may  gain  entrance  to  the 
crypts.  The  tonsillar  ring  of  WALDEYER,  as  a  whole,  undoubtedly 
plays  an  important  r61e  as  a  first  line  of  defense  against  infection, 
and  whatever  it  cannot  handle  is  propelled  along  the  lymph- 
stream  to  the  next  line,  the  lymph-glands,  where  they  produce 
the  characteristic  changes. 

Sclerosed  Tonsils  a  Menace. — The  opinion  that  only  the 
hypertrophied  tonsil  can  be  the  source  of  infection  seems  scarcely 
reasonable,  in  view  of  the  fact  that  repeated  inflammatory 
attacks  of  the  tonsils  often  leave  them  sclerosed  and  atrophic 
and  hence  less  able  to  deal  with  microorganisms  than  when  they 
are  of  normal  size.35  The  small  sclerosed  tonsil  may  increase 
the  facility  of  infection,  because  of  its  crypts  having  wider 
openings  on  the  buccal  surface  than  normal;  also  because  of 
atrophy  of  the  lymphatic  tissue. 

Frequency  of  Tonsillar  Tuberculosis. — Numerous  investiga- 
tions have  been  made  with  regard  to  tuberculosis  of  the  tonsil. 
Various  authors  have  collected  thousands  of  cases,  the  average 
findings  running  quite  parallel.  In  cases  where  no  tuberculous 
symptoms  are  present,  examination  of  the  tonsils  reveals  the 
presence  of  tuberculosis  in  from  4  to  6%. 

LOCKHARD  36  collected  1,988  cases  of  pharyngeal  and  faucial 
tonsillar  enlargements  and  found  tuberculosis  in  5.9%.  WOOD  37 
collected  1,671  cases  from  the  literature  with  tuberculosis  in 
5.2%.  G6RDELER38  reported  47  cases  with  12.75%  of  tuber- 
culosis. PYBUS39  collected  751  cases  with  6.7%  positive. 
STREET  40  examined  100  pairs  of  tonsils  removed  from  supposedly 
non-tuberculous  patients;  10%  of  these  tonsils  showed  tuber- 
culous processes  in  different  stages  of  development. 

Association  Between  Diseased  Tonsils  and  Cervical  Glands.— 
Examination  of  the  tonsils  associated  with  enlarged  cervical 
glands  reveals  a  higher  frequency  of  tuberculosis.  NICOLL  41 
examined  500  cases  of  chronic  enlargement  of  the  cervical  lymph- 
glands  in  children  and  a  great  number  of  hyperplastic  tonsils 
which  showed  signs  of  simple  inflammation  and  found  tuber- 
culosis in  80%.  He  believes  that  in  80%  of  the  enlarged  lymph- 
glands  the  cause  for  the  tuberculous  involvement  is  to  be  found 


PATHOLOGY  69 

in  the  hyperplasia  of  the  tonsils.  LOCKHARD  estimates  it  at  90%, 
GARDINER  and  PYBUS  80%.  But  these  estimations  seem  rather 
high.  Actual  findings  are  much  less.  GARDINER  42  in  examining 
tonsils  associated  with  cervical  adenitis  found  tuberculosis  in 
4  out  of  30  cases.  CARMICHAEL  43  7  out  of  50  cases,  KINGS- 
FORD  44  7  out  of  17,  MITCHELL  44  24  out  of  73,  and  KURD  and 
WRIGHT  44  9  out  of  12  cases,  which  gives  us  an  average  of 
28.17%. 

In  a  recent  article  MITCHELL  again  shows  that  primary 
tuberculosis  of  the  faucial  tonsils  is  by  no  means  so  rare  as  is 
generally  supposed  and  according  to  the  same  author  the  im- 
portance of  recognizing  it  as  a  primary  focus  cannot  be  too 
strongly  insisted  upon.  In  106  cases  of  tuberculous  cervical 
glands,  the  tonsils  were  found  to  be  tuberculous  in  38%.  In  this 
series  51  cases  were  found  to  have  small  and  submerged  tonsils, 
27  hypertrophied  and  28  tonsils  of  medium  size.  In  100  cases 
of  hypertrophied  tonsils  with  barely  palpable  cervical  glands 
9%  were  found  to  be  tuberculous. 

CORNET  44  does  not  believe  that  we  are  justified  in  attaching 
any  great  importance  to  the  tonsils  as  a  portal  of  entrance  in 
tuberculosis  of  the  cervical  glands,  to  say  nothing  of  making 
them  almost  entirely  answerable  for  their  causation;  other 
authors,  on  the  other  hand,  notably  AUFRECHT  and  GROBER  45 
consider  the  tonsil  to  be  one  of  the  most  frequent  points  of 
entry  of  tuberculosis,  and  that  tuberculosis  of  the  lungs  arises 
from  them. 

The  feeding  experience  of  GRIFFITH  46  include  a  total  of  92 
animals  and  give  us  undoubtedly  a  true  conception  of  the  con- 
ditions at  hand. 


7o        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 
TABULATED  ACCOUNT  OF  GRIFFITH'S  EXPERIMENTS 


Number  fed 

Number 

Number 

Species  of 

with  the 

tonsils 

neck  glands 

Animals 

material 

tbc 

tbc 

Chimpanzees 

7 

i 

4 

Rhesus  monks 

7 

i 

4 

Baboons 

14 

9 

ii 

Calves 

21 

3 

5 

Goats 

9 

i 

5 

Pigs 

34 

8 

21 

Number  Mesent.  and 

Int.  colic  gl. 

tbc  tbc 

7  7 

7  7 

13  13 

16  20 

2  8 

10  32 


TOTAL  92  23  50  55  87 

The  tonsils  in  this  series  then  show  an  involvement  of  25%, 
while  the  neck  glands  are  involved  in  54.3%.  The  conclusions 
would  then  not  seem  very  far  from  the  truth,  that  in  cases  of 
cervical  tuberculous  adenitis,  the  tonsils  are  responsible  for  the 
condition  in  about  50%  of  the  cases. 

Secondary  tuberculosis  of  the  tonsils  is  more  common  than 
the  primary.  It  may  be  the  result  of  infection  from  germ-laden 
sputum,  occurring  then  in  the  later  stages  of  pulmonary  tuber- 
culosis, or  it  may  appear  in  the  course  of  miliary  tuberculosis, 
then  being  due  to  infection  through  the  blood-stream.  In  either 
case  it  may  be  accompanied  by  involvement  of  the  cervical 
glands.  PYBUS  47  collected  115  cases  (Strassman,  Kruckmann, 
Walsham  and  Friedman)  in  which  examination  of  the  tonsils 
had  been  made  in  those  dying  from  tuberculosis  and  found  70 
positive  cases  or  60.8%;  in  those  who  died,  55  cases,  the  tonsils 
were  tuberculous  in  96.4%. 

Pharyngeal  Tonsil. — The  Pharyngeal  tonsil  or  the  tonsil  of 
Luschke,  is  located  in  the  vault  of  the  nasopharynx.  Hyper- 
trophy of  this  mass  of  lymphoid  tissue  is  commonly  known  as 
adenoids.  This  condition,  probably  due  to  repeated  irritations 
from  the  inspired  air,  forms  a  favorable  spot  for  the  deposit  of 
various  bacteria  contained  in  the  air.  The  air  current,  changing 
its  direction  in  the  vault  of  the  pharynx,  is  thrown  directly  on 
to  the  tonsils.  This  uneven  structure,  with  its  many  crypts, 
is  especially  suitable  for  retention  of  bacteria  and  is  undoubtedly 
responsible  for  a  certain  number  of  cases  of  cervical  adenitis. 


PATHOLOGY  71 

Tuberculous  infection  of  the  pharyngeal  tonsils  is  more  com- 
plicated than  that  of  the  palatine  tonsils.  Primary  infection 
may  occur  through  the  inspired  air,  but  infection  through  food 
is  impossible,  hence  hardly  any  opportunity  for  bovine  infection. 
Secondary  infection  by  means  of  sputum  is  very  difficult,  due  to 
closure  of  the  posterior  nares  during  attacks  of  coughing;  but, 
of  course,  infection  can  take  place  through  the  expired  air. 

The  actual  presence  of  tuberculosis  in  the  pharyngeal  tonsils 
is  estimated  differently  by  various  authors.  Some  go  so  far  as 
to  consider  this  tonsil  the  most  important  and  most  common 
portal  of  entry  for  the  tubercle  bacilli,  notably  BECKMANN. 
BLUMENFIELD  48  does  not  take  this  extreme  view,  but  believes 
that  the  adenoid  growths  play  a  definite  role  in  producing  tuber- 
culous adenitis  both  in  the  cervical  and  bronchial  regions. 

Examinations  of  the  adenoids  reduce  the  frequency  to  quite 
an  extent.  LACHMANN  49  collected  2,065  cases  with  histological 
examinations  and  inoculation  experiments  and  found  tuber- 
culosis 89  times,  or  4.3%.  SIMON  50  collected  1,361  cases  with  67 
positive,  i.  e.,  about  5%.  Hence  the  proportion  is  quite  com- 
parable with  tuberculous  involvement  of  the  faucial  tonsils. 

Mucous  Membrane  of  Nose,  Mouth  and  Pharynx. — According 
to  CORNET  and  MOST  the  mucous  membrane  of  the  nose  does 
not  form  a  negligible  portal  of  entry  for  the  tubercle  bacillus. 
It  is,  without  question,  one  of  the  most  exposed  mucous  mem- 
branes in  the  human  body.  The  germ-laden  inspired  air  is  con- 
stantly passing  over  it  and  catarrhal  conditions  of  the  nose  are 
common  enough  to  render  it  more  or  less  an  easy  prey  for  the 
penetration  of  the  tubercle  bacilli. 

Calmette's  Views. — But,  as  CALMETTE  51  remarks,  the  nasal 
mucous  membrane  does  not  permit  the  penetration  of  tubercle 
bacilli  as  easily  as  one  would  believe,  in  spite  of  the  rich  network 
of  lymphatics  and  veins,  in  spite  of  the  enormous  quantities  of 
dust  of  all  sorts,  which  accumulate  with  each  inspiration.  The 
reason  is,  according  to  the  same  author,  that  these  foreign  par- 
ticles exercise  a  positive  chemotaxis  upon  the  leucocytes;  these 
leave  the  capillaries  to  engulf  them,  but  before  they  reach  them 
they  are  immobilized  and  captured  on  the  surface  of  the  mucous 


72        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

membrane,  due  to  the  sticky  mucus  produced  by  the  glands. 
Deprived  of  their  motion  the  leucocytes  cannot  again  enter  the 
circulation  but  are  expelled  with  the  mucus.  Proof  of  this  is 
that  tubercle  bacilli  are  often  found  in  the  nasal  cavities  of  per- 
fectly sound  individuals  and  that  primary  infection  of  the  nasal 
mucosa  is  very  rare. 

Lockard's  Views. — LOCKARD  52  supposes  that  since  infection 
is  rarest  at  the  point  naturally  most  exposed  to  infection,  one 
must  assume  for  the  nasal  mucous  membrane,  or  its  secretions, 
some  strong  inherent  power  of  defense.  He  enumerates  the 
following  properties  of  the  nasal  mucosa  and  its  secretions  as 
having  an  important  bearing  upon  the  rarity  of  nasal  infection. 

The  peculiar  character  of  the  nasal  secretion  which  renders  it 
antagonistic  to  the  life  or  growth  of  morbific  germs.  The  ex- 
treme sensitiveness  and  reflex  irritability  of  the  nasal  mucous 
membrane,  whereby  the  inhalation  of  any  irritant  provokes 
almost  instantaneous  congestion,  swelling  of  the  erectile  tissues 
and  increased  flow  of  the  watery  secretions,  with  probable  ex- 
pulsion of  the  foreign  elements. 

The  increased  flow  of  secretions  and  the  action  of  the  cilia, 
plus  the  almost  constant  presence  of  a  film  of  mucus,  renders 
the  nasal  mucous  membrane  almost  a  negligible  factor  as  a  portal 
of  entry  for  tuberculous  infection. 

The  mucous  membrane  of  the  mouth  and  pharynx  with  the 
exception  of  the  tonsillar  region,  oppose  the  infection  in  the  same 
manner  as  the  nasal  mucous  membrane.  Tuberculous  lesions 
of  this  area  are  quite  rare;  the  tongue  may  sometimes  be  affected, 
also  the  gums;  the  pharynx  proper  is  very  rarely  the  seat  of 
primary  infection.53  But  the  possibility  of  bacillary  penetration 
is  not  to  be  entirely  overlooked. 

Cornet's  Experiments. — CORNET  believes  that  the  r61e  played 
by  this  part  of  the  mucous  membrane  is  quite  important  in  pro- 
duction of  cervical  adenitis.  In  his  experiments  on  animals,  he 
produced  tuberculosis  of  the  cervical  glands  by  rubbing  the  gums, 
back  of  the  pharynx  and  the  tongue,  with  tuberculous  material 
without  any  changes  whatever  occurring  at  the  point  of  inocula- 
tions. JOUSSET  54  is  of  the  opinion  that  the  chief  portal  of  entry 


PATHOLOGY  73 

for  the  tubercle  bacilli  is  the  upper  parts  of  the  digestive  and 
respiratory  tracts,  namely,  the  mucous  membrane  of  the  nose, 
throat  and  tonsils.  MEDIN  55  believes  that  the  mucous  mem- 
brane of  the  nose  and  pharynx  plays  a  very  insignificant  r61e  as 
portal  of  entry  in  infants. 

The  Teeth. — The  mouth  has  long  been  known  to  be  the  most 
septic  of  all  cavities  in  the  human  body,  still  it  is  only  lately  that 
oral  sepsis  has  begun  to  receive  the  attention  that  it  deserves. 
The  loose  carious  teeth  in  children  are  undoubtedly  the  greatest 
danger;  with  their  open  pulp  channels  and  ulcerating  sockets, 
they  are  portals  for  the  entrance  of  pathogenic  bacteria  of  every 
description. 

That  the  teeth  in  children  have  been,  up  to  the  present  time, 
the  most  neglected  members  of  the  body  by  both  the  physician 
and  the  dentist,  there  can  be  no  question.  I  believe  that  in  the 
near  future  it  will  be  demonstrated  that  the  present  methods 
of  treatment  of  diseased  deciduous  teeth  is  far  from  perfect. 
With  the  exception  of  the  tonsils,  it  is  the  teeth  and  their  imme- 
diate root-coverings  that,  without  question,  furnish  the  most 
important  portals  of  entry  for  infection.  BLAIR  56  describes 
three  distinct  routes: 

i — Open  pulp  canal 

2 — Diseased  peridental  membrane 

3 — Injuries  to  surrounding  tissues  by  the 

sharp  edges  of  carious  crowns  and  roots. 

Relation  between  Carious  Teeth  and   Cervical  Adenitis. — 

The  relation  between  carious  teeth  and  tuberculous  cervical 
glands  has  repeatedly  been  proven.  STARCK  57  examined  113 
children  with  cervical  adenitis,  and  proved  that  41%  of  the 
examined  cases  were  due  to  carious  teeth,  by  demonstrating  the 
presence  of  the  same  organism  in  the  gland,  teeth  and  the  con- 
necting lymphatic  vessels  in  some  cases,  or  by  showing  the  local 
dependence  of  the  glandular  swelling  upon  the  situation  of  the 
carious  tooth;  caries  of  the  posterior  molars  were  associated  with 
swellings  of  the  posterior  submaxillary  glands — the  canine  teeth 
with  those  of  the  anterior  gland.  PEDLEY  58  examined  3,145 
children  and  found  carious  teeth  present  in  77.5%  of  the  cases, 


74        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

associated  with  more  or  less  pronounced  cervical  lymphade- 
nitis. 

OdenthaTs  Findings. — ODENTHAL  59  examined  978  children, 
429  of  which  had  progressive  caries  of  the  teeth;  all  of  these, 
except  four,  had  cervical  lymphadenitis.  In  237  cases  the  teeth 
were  badly  broken  down  and  the  glandular  swellings  more  pro- 
nounced. In  359  cases  no  cause  of  the  enlarged  glands  could  be 
assigned  except  carious  teeth.  In  131  cases  caries  were  found 
on  one  side  only,  and  the  enlarged  glands  on  the  same  side. 
K6RNER60  examined  1,645  children  and  demonstrated  the  cor- 
respondence of  the  glandular  enlargement  with  the  affected  tooth 
both  as  to  position  and  degree  of  infection. 

Starck's  Case. — Absolute  proofs  are  not  lacking  to  show  the 
dependence  in  some  cases  of  tuberculous  cervical  adenitis,  upon 
carious  teeth.  Take  for  instance  a  case  reported  by  STARCK  61— 
an  1 8-year-old  boy  suddenly  developed  toothache  on  the  left 
side;  after  a  certain  period  of  time  a  swelling  beneath  the  left 
jaw  developed  and  gradually  increased  in  size;  the  gland  was 
proven  to  be  tuberculous  and  tubercle  bacilli  were  found  in  the 
carious  tooth.  ENLER  62  had  one  case  in  which  the  track  from 
the  tooth  to  the  tuberculous  granuloma  could  be  traced  by  the 
microscope. 

Tubercle  Bacilli  Found  in  Carious  Teeth. — Tubercle  bacilli 
have,  a  number  of  times,  been  found  in  carious  teeth.  COOK  63 
examined  220  mouths — saliva,  decayed  teeth  and  root-pulps,  and 
found  tubercle  bacilli  in  eleven  cases,  in  some  associated  with 
pulmonary  tuberculosis,  or  cervical  lymphadenitis — in  some 
associated  with  no  demonstrable  tuberculosis  anywhere. 

Moorehead's  Findings. — MOOREHEAD  64  has  reported  several 
cases  of  cervical  lymphadenitis  with  carious  teeth  and  the  actual 
findings  of  tubercle  bacilli  in  the  decayed  root-pulps.  MOELLER  65 
lays  stress  on  the  importance  of  carious  teeth  and  ulcers  of  un- 
clean mouths  as  portals  of  entry.  He  examined  53  healthy 
children  and  found  carious  teeth  in  26  cases,  and  foul  conditions 
of  the  mouth  in  41  cases.  No  tubercle  bacilli  were  found  in  the 
teeth,  but  six  times  in  the  sordes,  while  pseudotubercle  bacilli 
were  found  nine  times  in  the  teeth  and  eighteen  times  in  the 


PATHOLOGY  75 

sordes.  Amongst  194  children  with  diseased  lungs  he  found  153 
cases  of  carious  teeth  and  182  cases  of  ulcerations  of  the  mouth. 
Tubercle  bacilli  were  found  14  times  in  the  teeth  and  35  times 
in  the  ulcerations,  while  pseudotubercle  bacilli  were  found  23 
and  42  times  respectively. 

Wright's  Views. — A  point  brought  out  by  WRIGHT  66  that  un- 
doubtedly has  an  important  bearing  on  this  question  is  the  pres- 
ence of  hemolytic  streptococci  so  often  causing  small  abscesses 
around  the  root  ends.  These  germs  lower  the  vitality  of  the  tis- 
sues and  through  their  hemolytic  action  on  the  blood,  and  ad- 
jacent structures  render  a  pathway  for  the  invasion  of  tubercle 
bacilli.  These  statements  certainly  go  to  show  that  carious 
teeth  play  a  more  or  less  important  role  in  the  production  of 
tuberculous  cervical  adenitis ;  the  exposed  pulp  furnishes  an  open 
avenue  for  infection,  no  covering  mucous  membrane  being  present 
to  impede  its  progress.  The  presence  of  lymphatics  has  been 
definitely  proven  by  SCHWEIZER  and  hence  an  open  road  exists 
to  the  submaxillary  glands  which  are  intimately  connected  with 
the  deep  cervical. 

Eye,  Ear  and  Skin. — Experiments  on  animals  have  proven 67 
(Calmette,  Cornet)  that  tubercle  bacilli  may  pass  the  conjunc- 
tival  mucous  membrane  without  producing  any  changes  at  the 
place  of  entry,  but  soon  being  followed  by  the  development  of  a 
typical  adenitis.  In  man  the  conjunctiva  is  drained  by  the 
parotid  and  submaxillary  lymph-glands,  the  second  station  being 
the  superficial  and  deep  cervical  glands.  This  mode  of  infection 
hardly  plays  an  important  r61e  in  the  production  of  tuberculous 
cervical  adenitis.  Chances  for  infection  are  common  enough  by 
means  of  dirty  fingers,  handkerchiefs,  etc.,  but  the  protecting 
influence  of  the  lacrimal  secretion  and  the  nearly  perfect  drain- 
age provided  by  the  flow  of  tears  undoubtedly  forms  a  barrier 
which  is  hard  to  overcome  by  such  a  slowly  progressing  affair  as 
a  tuberculous  infection. 

Middle  Ear  and  Mastoid. — Primary  tuberculosis  of  the  middle 
ear  occurs  most  readily  in  children,  and  according  to  BANDELIER 
and  ROEPKE  68  is  limited  to  those  cases  in  which  chronic  middle 
ear  suppurations  afford  a  favorable  ground  for  infection,  which 


76        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

may  occur  either  from  outside  through  a  perforation  in  the  mem- 
brane, or  through  the  eustachian  tube.  FORDYCE  and  CAR- 
MICHAEL  69  call  particular  attention  to  the  danger  of  asphation 
up  the  eustachian  tube  during  the  act  of  sucking,  hence  giving 
another  pathway  for  bovine  infection  in  artificially  fed  babies. 

Primary  tuberculosis  of  the  mastoid  is  quite  frequent  in  chil- 
dren, 15%  of  all  cases  of  inflammatory  mastoid  disease  being 
tuberculous.70 

The  lymph-glands  involved  in  these  cases  are  the  auricular 
and  retro-pharyngeal,  from  which  the  process  travels  to  the  deep 
cervical. 

Skin  of  the  Face. — Of  all  the  organs  of  the  human  body  the 
skin  is  the  one  which  offers  the  least  favorable  conditions  for  the 
penetration  of  the  tubercle  bacilli.  In  spite  of  the  frequent  con- 
tact with  infected  material,  tuberculosis  of  the  skin  is  quite  rare. 
Experimentally  the  tuberculous  infection  can  be  made  to  traverse 
the  skin,  but  only  after  marked  rubbing  whereby  some  slight 
superficial  erosion  has  been  produced.  The  skin  of  the  face  is 
often  the  seat  of  small  lesions,  such  as  cracks,  fissures,  eczematous 
patches.  Through  these  infections  may  take  place. 

Scheltema's  Case. — SCHELTEMA  71  reports  the  case  of  an  eight 
weeks'  old  child  who  had  a  tuberculous  lesion  of  the  forehead  and 
involvement  of  the  regional  lymph-glands.  This  infant  had  had 
a  wound  on  the  forehead  and  had  been  taken  care  of  by  a  tuber- 
culous father.  The  sequence  of  events  is  obvious.  CHAN- 
CELLOR 72  reports  two  cases:  A  two  months'  old  baby  was  bitten 
on  the  cheek  by  a  tuberculous  nurse,  an  ulcer  developed  with 
subsequent  swelling  of  the  maxillary  and  cervical  lymph-glands. 
A  one-year  old  boy  was  wounded  on  the  neck  and  infected  by 
an  uncle  who  had  positive  sputum;  ulceration  with  subsequent 
cervical  adenitis  followed.  Cases  are  on  record  where  infection 
has  taken  place  through  the  wound  caused  by  piercing  the  ear- 
lobe  for  earrings. 

The  Scalp,  and  Pediculosis. — The  scalp  may  sometimes  fur- 
nish the  atrium  for  tuberculous  infection  with  subsequent  in- 
volvement of  the  occipital  and  deep  cervical  glands.  Pediculosis 
undoubtedly  plays  some  r61e  in  these  cases,  although  the  con- 


PATHOLOGY  77 

dition  is,  as  a  rule,  associated  with  eczematous  lesions  of  the 
scalp. 

Infection  of  the  Pre-laryngeal  Glands. — The  Pre-laryngeal 
gland,  or  glands,  located  in  front  of  the  crico-thyroid  membrane, 
is  often  involved  in  cases  of  endo-laryngeal  tuberculosis  and  may 
cause  involvement  of  the  deep  cervical  glands,  due  to  the  connec- 
tion existing  between  the  two  groups. 

Infection  of  the  Axillary  Glands. — The  Axillary  glands  drain 
the  skin  of  the  upper  part  of  the  thoracic  wall,  the  upper  abdom- 
inal region  and  the  upper  extremities.  They  are  also  connected 
with  the  lateral  group  of  the  inferior  deep  cervical  glands.  The 
avenues  of  infection  of  this  group  of  glands,  are  then  apparent. 
The  infection  through  the  upper  extremity  is  relatively  rare. 

JOUSSET  73  reports  how  he  infected  himself  with  virulent 
bovine  bacilli  through  a  wound  in  the  finger;  a  few  days  later  a 
tuberculous  nodule  appeared  with  swelling  of  the  axillary  lymph- 
glands.  It  occurs  generally  in  the  course  of  tuberculosis  of  the 
bones  of  the  hand  and  arms. 

Infection  of  the  Mammary  Glands. — Tuberculous  infection 
of  the  mammary  gland  is,  as  a  rule,  according  to  Mosx,74  due  to 
tuberculosis  of  a  rib  with  subsequent  infection  of  the  skin.  Be- 
cause connection  exists  between  the  lateral  group  of  the  supra- 
clavicular  or  inferior  deep  cervical  glands  and  the  axillary  glands, 
infection  of  the  latter  may  sometimes  be  the  result  of  spreading 
of  the  disease  from  the  former. 

Infection  of  the  Inguinal  Glands. — Tuberculosis  of  the  genital 
organs  is  associated  with  inguinal  adenitis.  The  female  genetalia 
are  more  commonly  affected  than  the  male.  In  infants  infection 
may  take  place  during  the  process  of  cleansing,  and  later  by  in- 
troduction of  various  foreign  bodies.  In  the  male,  the  most 
common  mode,  although  rare,  is  through  the  ritual  circumcision. 
HOLT  75  collected  41  cases  from  the  literature  in  which  the  opera- 
tion had  been  performed  in  the  usual  manner,  the  blood  being 
sucked  by  the  operator.  In  nearly  all  of  these  cases  the  respective 
families  were  free  from  tuberculosis,  while  the  operator,  on  the 
other  hand,  was  tuberculous.  Ulceration  of  the  operating  wound 
was  the  result,  with  subsequent  swelling  of  the  inguinal  glands. 


78        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

Tuberculosis  of  the  anal  mucous  membrane  is  usually  a  sec- 
ondary affair,  although  primary  cases  are  on  record;  the  in- 
guinal glands  draining  this  area  are  subsequently  involved. 

Role  of  the  Lymph-Glands  in  Tuberculous  Infection  hi  Chil- 
dren.— It  is  evident  that  the  lymph-glands  play  a  very  important 
part  in  the  struggle  of  the  organism  against  infection  with  tuber- 
culosis, especially  in  children,  who  are  particularly  liable  to  in- 
fection. By  reason  of  their  location  near  the  periphery  of  the 
body  and  in  positions  exposed  to  infection,  they  may  be  said  to 
constitute  a  second  line  of  defense  against  the  infection. 

They  Act  as  Filters. — Because  of  their  anatomical  structure 
they  are  well  adapted  to  act  as  protective  organs  and  niters  to 
the  lymph-stream,  being  composed  of  masses  of  lymphoid  cells 
encapsulated  with  fibrous  tissue  and  possessed  of  small  portals  of 
exit.  In  children  the  glands  are  better  fitted  to  combat  infection 
than  hi  adults  because  of  the  greater  abundance  of  lymphoid 
cells  and  the  lesser  amount  of  fibrous  tissue.  The  lymph-glands 
form,  on  account  of  their  capsules,  organs  which  are  entirely  en- 
closed except  for  the  afferent  and  efferent  vessels.  Toxins  pro- 
duced by  retained  bacteria  will  therefore  not  diffuse  themselves 
so  readily  into  surrounding  tissues.  The  concentration  of  the 
toxins  hinders  the  growth  of  the  bacteria  and  causes  a  reaction 
of  the  tissue,  coagulation  necrosis  resulting,  which,  together  with 
stasis  and  thrombosis  of  the  lymph  and  blood-vessels,  aids  in  the 
prevention  of  further  dispersal  of  the  bacteria. 

The  lymph-glands  often  sacrifice  their  existence  for  the  pro- 
tection of  the  organism.  The  fact  that  the  lymph-glands  advance 
the  infection  less  than  the  other  organs  cannot  be  denied.  In 
infancy  the  lymphatic  system  is  the  part  which  possesses  rel- 
atively the  greatest  power  of  resistance,  but  in  spite  of  this,  it  is 
not  capable  of  withstanding  the  assault  of  the  tubercle  bacillus 
and  there  is  a  marked  tendency  to  rapid  and  general  dissemination 
and  healing  rarely  occurs.  The  reaction  is  insufficient  and  the 
glands  fail  to  arrest  the  bacilli,  which  spread  through  the  lym- 
phatic system,  attack  other  tissues  and  cause  a  fatal  termination. 
Miliary  tuberculosis  and  tuberculous  meningitis  are  compar- 
atively frequent  and  evidence  of  this  tendency  to  dissemination. 


PATHOLOGY  79 

Glandular  tuberculosis  in  adults  is  of  less  importance,  but  the 
role  it  plays  in  childhood  is  very  great  and  it  is  now  generally 
believed  that  the  tuberculosis  of  the  adult  is  a  later  stage  of  the 
glandular  infection  in  childhood. 

In  most  cases  of  primary  infection  of  older  children,  the  tubercle 
bacilli  do  not  penetrate  beyond  the  regional  lymph-glands.  With 
caseation  and  the  production  of  allergy  the  infection  is  overcome 
completely  or  temporarily. 

MORBID  ANATOMY 

Formation  of  the  Tubercle. — When  the  tubercle  attacks  any 
organ  or  tissue  the  reaction  is  twofold.  One  constitutes  the 
response  of  the  organism  to  the  invading  bacilli  and  consists  of 
productive  and  protective  changes;  the  other  is  degenerative 
in  character  and  is  the  result  of  the  destructive  action  of  the  in- 
fective agent. 

The  commonest  product  of  the  tubercle  bacillus  is  the  tubercle. 
It  represents  a  new  growth  in  the  affected  tissue  and  consists, 
at  least  during  the  initial  stages,  of  derivatives  of  fixed  tissue 
cells.  The  condition  is  analogous  to  simple  inflammation  in 
which  exudative  and  cellular  processes  are  the  result  of  the  action 
of  an  irritant. 

Proliferative  processes  play  the  most  important  r61e.  The 
first  result  of  the  invasion  of  the  tissue  is  a  mitosis  of  connective 
tissue  and  endothelial  cells,  resulting  in  the  formation  of  ep- 
ithelioid  cells.  They  are  so  called  because  they  form  a  dense 
mass  and  are  connected  like  epithelial  cells.  Their  mutual 
arrangement  is  their  distinguishing  feature,  and  they  are  com- 
parable to  the  fibroclasts  of  simple  inflammation.  The  blood- 
vessels in  the  immediate  neighborhood  are  almost  always  oc- 
cluded by  compression  or  by  the  ingrowth  of  tubercle  into  their 
wall. 

Giant  Cell  Formation. — The  epithelioid  cells  may  be  converted 
into  giant  cells.  Their  formation  may  in  general  be  regarded  as 
the  expression  of  a  diminished  vital  activity.  Two  types  may 
be  considered,  according  to  the  method  of  their  formation.78 


8o        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

First,  the  proliferation  giant  cells  in  which  rapid  nuclear  division, 
often  amitotic,  occurs  without  division  of  the  cell  body;  second, 
the  conglutination  giant  cell  formed  by  the  fusion  of  two  or  more 
epithelioid  cells.  When  the  tubercle  has  grown  to  be  just  visible 
to  the  naked  eye  other  elements  gather  at  the  periphery.  Small 
round  cells  accumulate  at  first  hi  or  around  the  peripheral  zone, 
and  contribute  to  the  enlargement  of  the  nodule;  later  they  in- 
vade its  central  portions.  They  are  small  round  cells  with  deeply 
staining  nuclei  and  small  proto-plasmic  bodies  and  are  derived 
from  the  blood-vessels.  During  late  stages  polymorphous  nuclear 
leucocytes  also  appear  hi  addition  to  the  mononuclear  forms. 
They  collect  in  large  numbers  at  the  periphery.  In  addition  to 
the  cellular  elements  a  variable  quantity  of  fibrin  is  deposited  in 
the  central  and  peripheral  parts  of  the  tubercle. 

The  tubercle  has  a  delicate  fibrillar  reticulum  partly  derived 
from  the  fibrous  ground  substance  of  the  tissue  and  in  part  from 
newly  formed  fibers.  No  new  blood-vessels  are  formed  in  the 
structure  and  the  ones  involved  are  occluded  and  destroyed  by 
pressure  of  the  epithelioid  cells. 

Degenerative  changes  soon  set  in,  the  cause  for  which  is  to  be 
sought  in  the  toxic  products  produced  by  the  infective  agent  and 
in  the  a  vascular  condition  of  the  tubercle.  These  changes  begin 
in  the  centre  of  the  tuberculous  nodule  and  progress  in  concentric 
lines  toward  its  periphery.  The  giant  and  epithelioid  cells  are 
first  to  undergo  destruction  and  the  leucocytic  elements  soon 
follow.  The  degenerative  changes  result  in  caseation  necrosis 
in  which  the  protoplasm  fails  to  stain  and  shows  granular  and 
fatty  degeneration.  The  nuclei  become  fragmented  and  stain 
lightly  or  not  at  all,  and  the  final  result  is  a  dry,  firm,  bloodless 
mass.  In  the  end  the  necrosis  involves  the  fibrous  network  and 
the  trabeculae  of  fibrin. 

Foci  Undergo  Caseation. — Foci  which  have  undergone  com- 
plete caseation  frequently  become  the  seat  of  secondary  deposits 
of  calcareous  salts.  In  small  nodules  almost  complete  absorption 
may  result.  The  tubercle  may  become  encapsulated  by  fibrous 
changes.  The  epithelioid  cells  are  genetically  connective  tissue 
cells  and  they  may  undergo  transformation,  lengthen  and 


PATHOLOGY  81 

develop  fibroblasts  and  connective  tissue,  converting  the  tu- 
bercle into  a  purely  fibrous  structure.  A  certain  amount  of 
secondary  connective  tissue  formation  occurs  in  the  surrounding 
tissue. 

Tuberculosis  of  the  lymphatic  glands  is  not  always  associated 
with  the  typical  tubercle  formation.  The  earliest  change  is 
often  simple  hyperplasia  with  consequent  swelling.  In  certain 
cases  the  only  change  may  be  one  of  hyperplasia  characterized 
by  the  transformation  of  the  normal  gland  tissue  into  large  celled 
tissue,  having  none  of  the  characteristics  of  the  original  structure 
and  consisting  partly  of  rounded  and  polygonal  cells  and  partly 
of  spindle  cells.  Such  glands  remain  discrete  and  may  resemble 
those  of  Hodgkin's  disease.  There  is  little  tendency  to  caseation 
except  in  the  late  stages.  BARTEL  77  was  able  to  demonstrate  in 
the  lymph-glands  of  animals,  in  addition  to  manifest  tuberculosis 
in  the  specific  tuberculous  changes,  a  stage  of  lymphoid  tuber- 
culosis in  which  the  glands  showed  mainly  lymphatic  hyperplasia 
or  were  but  little  changed.  The  picture  suggests  infection  of  low 
virulence. 

Glandular  Chains  Involved. — Any  of  the  lymph-glands  of  the 
body  may  be  involved  but  the  cervical,  tracheo-bronchial  and 
mesenteric  •  glands  are  most  often  affected,  by  reason  of  their 
draining  areas  of  the  mucous  membranes  of  the  body  which  are 
the  most  common  portals  of  entry  of  the  tubercle  bacillus.  The 
glandular  infection  is  usually  lymphogenous,  rarely  hemato- 
genous,  in  origin.  The  further  spread  through  the  body,  from 
the  portal  of  entry,  takes  place  in  a  regular  manner  and  the 
atrium  of  infection  can  almost  always  be  concluded  with  cer- 
tainty from  the  pathological  condition  of  the  glands  in  which 
the  disease  is  further  developed.  In  the  mean,  the  infection 
follows  the  course  of  the  lymph-stream,  forming  a  chain  of  glands 
like  a  row  of  beads  which  gets  smaller  as  it  approaches  the  centre. 
It  extends  from  the  place  of  infection  in  a  circumscribed  manner 
as  the  process  radiates,  on  account  of  the  numerous  anastomosing 
branches  which  connect  the  lymph- vessels  one  with  the  other; 
now  and  again  it  extends  sideways  and  sometimes,  but  rarely, 
retrogrades. 


82        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

Bronchial  Glands. — It  is  a  well  known  fact  that  enlarged  and 
caseous  bronchial  glands  are  among  the  most  conspicuous  morbid 
changes  observed  in  tuberculous  children,  and  in  necropsies  they 
are  almost  always  found  to  be  involved.  So  conspicuous  indeed 
are  they  that  up  to  recent  years  they  have  been  considered  to  be 
the  primary  lesion  of  tuberculosis.  PARROT,  HEDREN,  ALBRECHT 
and  GHON  have  shown  that  the  bronchial  gland  infections  are, 
in  a  majority  of  instances,  caused  by  and  consecutive  to  an  initial 
lesion  located  in  the  lungs. 

Glands  May  Calcify. — The  mediastinal  glands  may  be  in- 
volved secondarily  to  tuberculosis  of  the  sternum,  ribs  and  ver- 
tebrae, clavicle  or  mammary  gland.  Some  writers  hold  that  the 
entrance  of  tubercle  bacilli  into  the  lymph  in  any  part  of  the 
body  may  cause  tuberculous  bronchial  glands.  The  bronchial 
nodes  on  the  right  side  are  more  frequently  and  more  extensively 
involved  but  it  is  not  uncommon  for  both  sides  to  be  affected. 
Calcified  scars  indicate  that  it  is  possible  for  the  lesions  to  be- 
come quiescent  but  in  childhood  calcification  is  rare.  In  the  dis- 
eased glands  caseous  degeneration  is  commonly  observed.  Only 
part  of  the  gland  may  be  affected,  but  when  tuberculosis  has  been 
the  cause  of  death  the  whole  gland  is  usually  caseated.  The 
caseous  mass  is  surrounded  by  fibrous  tissue  which  adheres 
strongly  to  neighboring  organs.  When  swollen,  the  glands  en- 
croach upon  and  cause  compression  of  surrounding  structures, 
giving  rise  to  various  pressure  symptoms.  Bronchial  glands 
occasionally  suppurate.  When  they  soften  they  may  burst 
into  the  mediastinum  or  form  adhesions  with  and  discharge 
into  neighboring  organs  or  on  the  surface  of  the  chest.  They 
may  open  into  the  trachea,  a  bronchus,  the  cesophagus,  pleura, 
pericardium,  or  erode  a  large  vessel.  The  latter  event  may  cause 
fatal  hemorrhage. 

Cervical  Glands. — The  cervical  glands  are  the  most  common 
site  of  external  glandular  tuberculosis.  The  submaxillary  group 
and  the  nodes  along  the  internal  jugular  vein  are  the  ones  most 
often  involved.  The  glandular  enlargements  are  usually  more 
extensive  on  one  side  than  on  the  other.  In  the  initial  stages 
the  glands  are  firm  in  consistency,  and  the  individual  nodes  can 


PATHOLOGY  83 

be  felt.  They  gradually  increase  in  size  and  may  remain  discrete, 
but  more  commonly  periadenitis  binds  the  glands  together  in 
irregular  masses.  Subsequently  there  is  caseation  and  softening. 
Inflammation  within  the  gland  is  followed  by  inflammation  in 
the  surrounding  tissues  which  results  in  adhesions  or  in  abscess 
formation.  The  abscess  may  be  confined  within  the  gland  or 
involve  the  surrounding  tissues.  The  skin  ultimately  becomes 
adherent  and  the  abscesses,  unless  opened,  burst  and  leave 
sinuses  which  heal  slowly  and  leave  disfiguring  scars.  In  other 
cases  the  pathological  process  advances  more  slowly  and  a  greater 
amount  of  fibrous  tissue  is  produced.  The  glands  in  such  in- 
stances are  tough  and  hard  and  the  capsules  are  greatly  thickened. 
They  less  frequently  form  adhesions  to  the  surrounding  tissues, 
and  suppuration  is  uncommon.  Calcification  of  the  cervical 
glands  is  rare.78 

As  has  been  shown  under  pathogenesis,  the  tonsils  serve  in  a 
great  number  of  cases  as  portals  of  entry  for  the  tubercle  bacilli. 
Macroscopical  manifestation  of  the  conditions  is,  as  a  rule, 
wanting;  microscopical  study  of  the  tonsil,  however,  reveals  the 
tubercles  situated  near  the  deeper  portions  of  the  crypts,  and 
also  directly  beneath  the  surface  mucosa.  These  are  the  most 
common  situations;  they  may  sometimes  be  located  deep  in 
the  tonsil  close  to  the  capsule.  The  tonsils  may  be  small  and  sub- 
merged, hypertrophied  or  of  medium  size.79 

Mesenteric  Glands. — The  changes  which  the  mesenteric  glands 
undergo  when  infected  with  tuberculosis,  differ  in  no  way  from 
those  met  with  in  lymphatic  glands  similarly  involved  in  other 
parts.  These  tuberculous  nodes  are  from  one-half  to  one  inch 
in  diameter,  occasionally  larger;  from  the  fusion  of  several  of 
them  may  result  tumors  of  considerable  size.  Primary  lesions 
in  the  lymphoid  structures  of  the  intestine  may,  or  may  not,  be 
present.  The  usual  termination  of  such  glands  is  in  calcification; 
rarely  an  abscess  forms  which  may  discharge  into  the  bowel  or 
into  the  peritoneal  cavity,  giving  rise  to  a  tuberculous  peritonitis. 
Localized  plastic  peritonitis  is  found  in  all  marked  cases  and  may 
lead  to  adhesions. 

The  usual  pathological  changes  are  observed  in  the  inguinal, 


84        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

axillary  and  other  glands  when  they  are  tuberculous.  In  rare 
instances  a  generalized  tuberculous  adenitis  occurs. 

Tuberculous  Lymphangitis.— Although  the  lymph-channels 
leading  from  one  lymphatic  structure  to  another  are  often  tuber- 
culous this  is  usually  lost  sight  of  in  the  general  involvement 
of  the  tissues.  In  connection  with  tuberculous  intestinal  ulcers 
and  mesenteric  glands  little  crops  of  tubercles  may  often  be  seen 
in  the  lymph- vessels  of  the  intestinal  serosa.  The  lymph-channels 
in  the  mesentary,  in  such  cases,  may  become  occluded  and  dis- 
tended with  chyle.  Rarely  the  cutaneous  lymphatics  become 
diseased,  especially  those  of  the  forearm,  following  tuberculous 
infection  of  the  fingers.  Cutaneous  nodules  then  result  which 
may  break  down  and  cause  ulcer ations  of  the  skin.  Tubercles 
may  grow  into  the  thoracic  duct  or  tubercles  in  its  vicinity  may 
rupture  and  their  contents  flow  into  the  duct  and  lead  to  general 
dissemination  of  the  bacilli  and  miliary  tuberculosis. 

Amyloid  Degeneration. — In  cases  of  long  standing  tuberculous 
adenitis  with  chronic  suppuration,  amyloid  degeneration  often 
occurs.  It  consists  in  the  formation  of  deposition,  primarily 
in  the  ground  substance  of  the  blood-vessels  and  connective 
tissues  and  especially  in  the  middle  coat  of  the  smaller  arteries, 
of  a  homogeneous  appearing  albumoid  substance.  The  spleen, 
liver,  kidneys,  intestines  and  stomach  are  the  organs  most  com- 
monly affected.  The  amyloid  substance  shows  characteristic 
staining  reactions,  e.  g.,  a  mahogany  brown  color  is  imparted  to 
it  by  iodine  solution.  Amyloid  disease  is  quite  persistent,  but 
it  may  undergo  surprising  improvement  in  childhood  if  the  pri- 
mary condition  is  relieved.80 


CHAPTER  VI 
SIGNS  AND  SYMPTOMS 

Tuberculous  adenitis  has  several  characteristics  which  are  of 
interest.  The  local  character  of  the  disease  is  a  prominent  feature. 
The  cervical,  bronchial  or  mesenteric  glands  may  be  alone  in- 
volved and  only  in  rare  instances  is  general  tuberculous  adenitis 
noted.  The  local  character  of  the  disease  is,  however,  no  longer 
looked  upon  as  a  localized  expression  of  a  diathesis,  but  as  a 
distinct  evidence  of  a  tuberculous  infection.  This  local  char- 
acteristic of  the  disease  is  not  accidental  and  calls  one's  attention 
to  the  common  portals  of  entry  of  infection,  the  respiratory  and 
gastro-intestinal  tracts. 

The  course  of  the  disease  is  chronic,  the  lesions  persisting  over 
a  considerable  period  of  time.  The  struggle  between  the  in- 
fective agent  and  the  protective  forces  of  the  lymphatic  glands 
is  a  long  one.  There  is  a  tendency  to  spontaneous  healing,  the 
protective  forces  being  sufficient  as  evidenced  by  the  frequent 
finding  of  calcified  remnants  of  bronchial  and  mesenteric  glands. 
However,  the  infection  may  persist  for  a  long  period  of  time  and 
break  out  afresh  and  result  in  an  acute  tuberculosis. 

At  the  present  time  this  endogenous  mode  of  infection,  occur- 
ring in  later  life  as  a  result  of  intercurrent  conditions  of  disease 
or  unfavorable  environment  and  lowered  resistance,  is  regarded 
as  the  most  probable  source  of  clinical  tuberculosis  in  the  adult. 
Tuberculous  adenitis  has  thus  assumed  a  position  of  importance; 
the  recognition  of  this  fact  has  a  most  important  bearing  upon 
the  question  of  prophylaxis.  Tuberculous  adenitis  is  met  with 
at  all  periods  of  life,  and  may  be  noted  even  in  old  age,  but  is 
much  more  common  during  childhood  and  early  adult  years. 
The  most  common  time  of  occurrence  is  between  the  first  denti- 
tion and  the  time  of  puberty.  EDWARDS  1  states  that  68%  of  the 
glandular  adenopathies  are  observed  during  the  first  ten  years  of 


86    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

life.  The  question  of  sex  incidence  is  of  lesser  import.  Most 
observers  are  agreed  that  females  preponderate.  In  WOHLGE- 
MUTH'S  2  series  of  430  cases.  223  were  females  and  207  males. 
In  the  author's  series  of  270  cases,  109  were  males,  and  161 

females. 
Bronchial  Glands.— The  bronchial  glands  are  subdivided  into 

the  following  sub-groups: 3 

1.  The  tracheo-bronchial  glands,  situated  in  the  lateral  angles 
between  the  trachea  and  bronchus  on  each  side.    Their  afferent 
vessels  come  from  the  other  groups  of  bronchial  glands  and  ad- 
jacent parts  of  the  trachea  and  bronchi.    The  efferent  vessels 
pass  to  the  broncho-mediastinal  trunk. 

2.  The  lymph-glands  of  the  bifurcation  located  in  the  angle 
between  the  two  main  branches.    They  are  nine  to  twelve  in 
number  and  drain  the  adjacent  parts;  they  also  receive  the 
afferent  vessels  of  the  broncho-pulmonary  glands;  their  efferent 
vessels  pass  to  the  tracheo-bronchial  glands. 

3.  The  broncho-pulmonary  glands  are  embedded  in  the  hilus 
of  the  lung  and  drain  the  lung  substance  directly  or  through 
the  pulmonary  glands;  their  efferent  vessels  may  go  directly 
into  the   tracheo-bronchial  glands  or  via  those  of  the  bifur- 
cation. 

4.  The  pulmonary  lymph-glands  are  situated  in  the  lung  sub- 
stance which  they  drain;  the  efferent  vessels  pass  to  the  broncho- 
pulmonary  glands. 

In  tuberculosis  of  children,  the  bronchial  glands  are  the  most 
frequent  site  of  localization  and  are  almost  always  involved. 
This  is  evidenced  by  post-mortem  findings.  In  NORTHRUP'S  4 
series  of  autopsies  on  tuberculous  children,  these  glands  were 
involved  in  100%  of  the  cases,  and  in  61%  of  cases  in  adults. 
The  nodes  on  the  right  side  are  more  frequently  and  extensively 
involved  than  those  on  the  left.  WOLLSTEIN  5  found  the  largest 
nodes  on  the  right  side  in  14%  of  cases.  It  is  not  uncommon  for 
both  sides  to  be  affected.  We  have  seen  that  the  bronchial  nodes 
are  a  common  site  of  latent  infection  which  may  be  dormant  and 
inactive  for  years,  giving  rise  to  no  clinical  manifestations.  In 
fact,  at  post-moitem  there  may  be  no  pathological  evidence  of 


PLATE   VII. — Tuberculosis  of   the  bronchial  glands  in   an   adult.    From  X-Ray 
Laboratory  of  Maximilian  J.  Hubeny,  M.  D. 


SIGNS  AND  SYMPTOMS  87 

infection,  it  being  demonstrable  only  by  animal  inoculation. 
Infection  of  these  glands  therefore  frequently  eludes  clinical 
recognition.  They  are  in  relation  to  the  trachea,  bronchi, 
oesophagus,  superior  vena  cava,  vagus  and  recurrent  laryngeal 
nerves.  When  greatly  swollen  they  may  be  in  contact  with  the 
arch  of  the  aorta  and  the  innominate  veins.  The  symptoms  and 
signs  are  those  of  pressure  upon  these  structures,  together  with 
the  toxic  symptoms  characteristic  of  a  chronic  tuberculous  proc- 
ess. In  a  great  many  instances  slight  involvement  causes  no 
symptoms.  In  a  majority  of  cases  the  symptoms  are  not  marked. 
While  children  with  tuberculosis  of  these  nodes  are  usually 
delicate,  such  is  not  always  the  case. 

General  Symptoms. — The  early  symptoms  are  toxic  in  origin 
and  vary  in  intensity  with  the  degree  of  the  toxemia.  The  onset 
is  generally  insidious,  the  condition  passing  very  gradually,  often 
imperceptibly  from  one  of  health  to  that  of  disease.  Disease  of 
the  glands  may  have  progressed  to  a  considerable  extent  before 
the  child,  for  it  occurs  most  often  in  children,  is  known  to  be  ill. 
Lack  of  evident  cause  for  change  in  the  general  condition  is  truly 
characteristic  of  tuberculosis  of  the  tracheo-bronchial  glands, 
and  it  certainly  is  of  more  frequent  occurrence  without  any 
special  symptoms  than  with  them. 

Nervous  Manifestations. — The  general  condition  gradually 
becomes  undermined,  leading  to  an  irregular  and  indefinite  state 
of  ill  health.  An  early  symptom  is  a  sense  of  undue  fatigue  after 
ordinary  exertion,  often  languor  and  lassitude.  With  a  decrease 
in  strength,  the  child  becomes  irritable,  restless  and  fretful  and 
his  sleep  is  disturbed.  In  older  individuals  the  depression  and 
irritability  may  advance,  until  it  reaches  a  condition  of  typical 
neurasthenia. 

Gastro-mtestinal  Disturbances. — The  appetite  may  be  lost 
or  capricious,  and  these  patients  often  show  a  marked  aversion 
to  fats.  More  or  less  digestive  disturbances  are  frequent.  In 
the  early  stages,  hyper-acidity  may  be  present  and  later  sub- 
acidity.  The  nutrition  gradually  becomes  impaired.  In  well 
marked  cases  the  child  may  stop  growing  or  be  undersized.  Anae- 
mia develops  slowly  and  pallor  of  the  face  and  mucous  mem- 


88        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

branes  may  appear  so  gradually  that  it  is  not  noted,  until  it  has 
existed  for  some  time.  The  reduction  of  hemoglobin  and  chlo- 
rosis may  be  a  masked  tuberculosis.  The  leucocytes  may  be 
normal  or  show  a  slight  increase.  In  uncomplicated  tuberculosis 
a  leucopenia  is  not  uncommon.  Disturbances  of  the  body  tem- 
perature are  a  result  of  the  absorption  of  the  toxic  products  of 
the  tubercle  bacilli.  Fever  is  not  a  prominent  feature  in  tuber- 
culosis of  the  tracheo-bronchial  glands.  There  is  no  character- 
istic type,  and  many  are  free  from  temperature.  In  incipiency, 
there  is  an  increase  in  temperature  only  after  exertion,  and  it 
subsides  to  normal  after  an  hour's  rest. 

Temperature  Changes. — The  temperature  is  more  apt  to  be 
low  in  the  morning  and  may  reach  99  or  99.5  degrees  F.  in  the 
afternoon,  the  rise  being  slight  but  regular.  Very  often  the  tem- 
perature is  sub-normal  and  may  be  so  constantly  or  increase  at 
night.  In  a  few  more  active  cases,  there  are  long  febrile  periods 
in  which  the  temperature  is  found  to  be  raised  more  or  less  con- 
tinuously. In  tuberculous  children  an  increase  in  temperature 
is  easily  excited.  Sweating  at  night  may  be  noted,  but  is  of  little 
significance  as  it  is  frequent  in  children  even  under  normal  con- 
ditions. 

Pressure  Symptoms. — When  the  tracheo-bronchial  glands 
become  enlarged  to  an  appreciable  extent,  symptoms  may  be 
produced  from  pressure  upon  or  irritation  of  neighboring  struc- 
tures. A  spasmodic,  metallic,  non-productive  cough  is  often 
the  first  symptom  to  excite  suspicion  of  disease  of  these  glands. 
In  young  children  it  may  occur  in  severe  paroxysms  resembling 
pertussis.  It  is  not  a  constant  symptom,  and  I  have  seen  cases 
in  which  the  glands  had  reached  a  large  size  with  practically 
no  cough.  Dyspnoea  may  be  a  marked  symptom  especially  in 
infants  and  younger  children.  It  is  most  commonly  expiratory 
in  character.  In  spite  of  it,  the  voice  or  cry  is  clear,  showing  that 
it  is  not  laryngeal  in  origin.  It  is  due  seemingly  to  pressure  on 
the  vagus  or  directly  on  the  trachea  and  bronchi.  ScmcK6 
thinks  that  compression  of  the  trachea  and  bronchi  occurs  more 
frequently  than  is  usually  stated.  He  also  observed  that  the 
dyspnoea  was  more  apt  to  be  present  when  the  child  was  resting 


SIGNS  AND  SYMPTOMS  89 

quietly,  and  that  a  hard  attack  of  coughing  or  a  disturbance 
would  cause  it  temporarily  to  disappear. 

Dyspnoea  of  inspiratory  character  may  result  from  pressure 
on  the  recurrent  laryngeal  nerve  due  to  paralysis  of  the  dilators 
of  the  larynx.  Hoarseness,  or  aphonia,  laryngospasm,  and 
asthmatic  attacks  may  also  occur. 

Sometimes  more  or  less  constant  pain  within  the  chest  is  com- 
plained of.  It  is  rarely  definitely  located  but  is  usually  in  the 
mid-thoracic  region.  It  may  be  sharp  and  lancinating  in  char- 
acter and  be  brought  on  by  deep  breathing  or  exertion.  Severe 
pain  may  be  felt  in  the  region  of  the  upper  dorsal  vertebrae. 
Pressure  upon  the  large  intra-thoracic  veins  results  in  congestion 
of  the  mucous  membrane  of  the  respiratory  tract.  As  a  result, 
epistaxis  and  the  expectoration  of  small  amounts  of  blood  are 
not  uncommon  occurrences.  STOLL  7  regards  hemorrhage  with- 
out evidence  of  cardiac  or  pulmonary  lesions  as  due  to  bronchial 
node  enlargement. 

Tachycardia  is  frequent  and  is  probably  due  in  large  part  to 
pressure  upon  the  vagus  although  the  direct  effect  of  the  toxins 
upon  the  heart  muscle  is  a  factor  to  be  considered.  Pressure  of 
the  enlarged  glands  may  cause  difficulty  and  pain  in  swallowing. 

Physical  Signs.  Inspection. — Individuals  with  tuberculous 
infection  of  the  tracheo-bronchial  glands  may  show,  on  inspection, 
no  particular  evidence  of  it  and  be  well  nourished.  If  the  tuber- 
culous infection  has  been  active  for  some  time,  however,  general 
signs  and  symptoms  may  be  noted.  These  general  signs  were 
formerly  looked  upon  as  indications  of  a  predisposition  to  tuber- 
culosis, but  are  to-day  regarded  as  evidence  of  an  infection,  which 
is  flooding  the  system  with  toxins. 

The  trained  eye  appreciates  the  general  appearance  of  these 
individuals.  Children  are  often  tall  for  their  age,  or  at  least 
appear  to  be  on  account  of  the  disproportion  between  the  width 
and  height  of  their  chests.  Their  long  slender  necks  enhance  the 
effect.  The  fingers  are  long  and  thin  and  the  distal  digits  may 
be  club-shaped.  The  skin  is  apt  to  be  dry  and  scaly  and  loss  of 
flesh  is  indicated  by  its  laxity.  The  hair  is  often  soft,  thick  and 
luxuriant,  the  eyebrows  well  marked  and  lashes  long  and  silky. 


90        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

A  special  type  of  fades,  "tuberculous  fades,"  has  been  noted, 
the  face  oval  in  outline,  the  features  delicate  and  pinched  and 
the  expression  wistful.  The  eyes  are  bright  and  appealing  and 
the  sclera  bluish  white.  The  pupils  are  often  dilated,  indicating 
pressure  by  the  enlarged  glands  upon  the  sympathetic.  When  of 
unequal  size  the  process  is  more  active  on  the  side  showing  the 
greater  dilatation. 

The  posture  in  standing  is  relaxed,  the  chest  long  and  often 
stooped  and  its  circumference  subnormal.  The  scapulae  are 
situated  low  and  are  projecting  and  prominent.  The  acromial 
end  of  the  clavicle  is  sunken  and  the  shoulders  converge  ante- 
riorly. The  sternum  may  be  arched  forward  to  a  slight  extent.8 
In  most  severe  cases  long  continued  laryngospasm  may  so  inter- 
fere with  the  entrance  of  air  into  the  lungs  that  the  anteroposte- 
rior  diameter  of  the  chest  becomes  prominent.  In  older  children 
there  may  be  seen  the  so-called  hilus  dimple,  a  depression  visible 
in  the  second  and  third  interspaces  near  the  parasternal  line  when 
the  breath  is  held  at  the  end  of  inspiration. 

A  tracery  of  enlarged  venules  interweaving  across  the  chest 
is  a  common  sign  of  glandular  pressure.9  They  are  most  often 
seen  in  the  second  interspace  between  the  border  of  the  sternum 
and  the  inner  half  of  the  clavicle;  less  commonly  they  are  found 
in  the  first  and  third  interspaces  also.  The  enlargement  is  usually 
greater  on  the  right  than  on  the  left  side.  When  the  tracheo- 
bronchial  glands  become  greatly  enlarged  they  cause  pressure 
upon  the  superior  vena  cava  and  one  or  both  innominate  veins. 
With  great  obstruction  to  the  return  of  blood  from  the  head,  the 
superficial  veins  may  be  visible  in  the  temples  and  neck  as  well 
as  over  the  front  of  the  chest.  There  may  be  a  certain  degree  of 
cyanosis  of  the  face,  and  the  skin  has  a  bluish  tinge,  especially 
about  the  mouth.  There  may  also  be  oedema  with  puffiness  of 
the  lips  and  eyelids.  The  cyanosis  and  oedema  are  usually  inter- 
mittent and  when  only  one  innominate  is  involved  may  be  more 
or  less  limited  to  one  side  of  the  face. 

Palpation.— PETRUSCHKY  10  called  attention  to  the  tenderness, 
on  pressure,  over  the  mid-thoracic  region  posteriorly.  It  is 
found  in  children  and  adults  when  the  toxic  symptoms  are 


PLATE  VIII. — Tuberculosis  of  the  bronchial  glands  in  a  child.  Age  12  years. 
From  X-Ray  Department,  Children's  Memorial  Hospital,  Chicago.  Kindness  of 
Coleman  G.  Buford,  M.  D. 


SIGNS  AND  SYMPTOMS  91 

marked,  but  is  not  found  in  latent  cases  or  advanced  stages  of 
tuberculosis.  Palpation  often  reveals  the  pressure  of  enlarged 
glands  in  the  cervical  region.  In  fact,  tuberculous  bronchial 
glands  may  be  demonstrated  by  the  Roentgen  Ray  in  cases  of 
cervical  adenitis  in  which  they  were  giving  rise  to  no  symptoms 
and  unsuspected. 

Percussion. — Demonstration  of  enlargement  by  percussion  is 
a  very  difficult  procedure.  They  lie  deeply  and  on  first  considera- 
tion it  would  seem  quite  unlikely  that  they  could  be  thus  detected. 
It  is  only  in  the  event  of  considerable  and  extensive  enlargement 
that  dulness  can  be  demonstrated.  I  believe  that  percussion  is 
of  value  in  such  cases  if  sufficiently  delicate. 

To  percuss  the  chest  posteriorly  the  patient  should  be  seated 
on  a  stool  or  table  with  the  arms  crossed  over  the  chest  to  the 
opposite  shoulders.  The  head  is  flexed  forward  to  secure  relax- 
ation of  the  spinal  muscles.  A  delicate  percussion  stroke  upon 
the  finger  of  the  opposite  hand  held  firmly  against  the  chest  wall 
is  employed.  I  emphasize  the  fact  that  the  percussion  stroke 
must  be  light.  A  tapping  stroke  will  elicit  dulness,  which  is 
imperceptible  when  greater  force  is  used,  by  reason  of  the  in- 
clusion of  resonant  lung  tissue  within  the  percussion  sphere. 
RIVIERE  n  states  that  there  exists  normally  on  either  side  of  the 
spine,  between  the  first  and  fifth  dorsal  vertebra  and  extending 
one  inch  from  the  mid  line,  an  area  of  slightly  impaired  resonance 
demonstrable  by  gentle  percussion.  Another  observer  believes 
he  is  able  to  detect  a  normal  area  of  dulness  at  the  root  of 
the  lung  opposite  the  fifth  dorsal  vertebra,  the  area  being  slightly 
larger  on  the  right  than  on  the  left.12 

With  enlarged  bronchial  glands  the  impaired  resonance  may 
extend  outward  two  or  three  inches  from  the  mid  line  and  may 
extend  down  to  the  sixth  or  eighth  dorsal  spine.  RIVIERE  lays 
much  stress  upon  this  dulness,  which  is  most  marked  on  the  right 
side  at  the  level  of  the  fifth  or  sixth  dorsal  spine. 

Vertebral  dulness  is  less  frequent  than  paravertebral.  In 
adults  a  dull  note  is  normally  present  over  the  first  four  dorsal 
spines.  A  distinctly  dull  note  below  the  fourth  dorsal  is  abnor- 
mal and  may  indicate  enlargement  of  the  tracheo-bronchial 


92        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

glands.  In  young  children  a  resonant  note  is  heard  over  the 
fourth  and  not  infrequently  over  the  third  dorsal  spine.13  It  is 
much  less  common  to  obtain  dulness  from  the  bronchial  nodes 
anteriorly.  When  the  nodes  about  the  right  bronchus  are  of 
considerable  size,  it  is  sometimes  obtained  in  the  second  inter- 
space to  the  right  of  the  sternum.  If  the  tracheal  glands  are 
much  enlarged,  dulness  may  be  found  in  the  first  interspace  near 
the  right  sternal  margin  and  over  the  right  half  of  the  manubrium. 
Dulness  may  also  be  noted  along  the  left  sternal  margin  as  low 
as  the  base  of  the  heart  and  great  vessels.  A  tympanitic  note 
may  be  found  over  the  apex  denoting  relaxation  of  the  lung. 
According  to  various  observers  the  glandular  enlargement  does 
not  of  itself  account  for  all  of  the  dulness.  NAGEL  14  believes 
that  there  is  an  actual  lessening  of  lung  tissue  by  displacement. 
KRAMER  15  believes  that  enlargement  of  the  mediastinal  blood 
and  lymphatic  vessels,  as  a  result  of  obstruction  at  the  hilus  of 
the  lung,  is  responsible  for  a  considerable  amount  of  dulness  since 
the  Roentgenogram  shows  the  glands  to  be  smaller  than  the 
area  of  impaired  resonance  indicates.  Another  thinks  the 
stasis  insignificant  and  the  inflammatory  condition  of  the  hilus 
structure  to  be  the  chief  factor.16 

Auscultation. — Auscultation  is  a  valuable  and  a  more  trust- 
worthy method  of  examination.  As  the  bronchial  glands  be- 
come enlarged  the  vesicular  quality  may  occasionally  be  replaced 
by  bronchial  breathing.  It  is  heard  more  clearly  posteriorly 
in  the  inter-scapular  space  and  more  often  on  the  right.  It  is 
less  high  pitched  and  more  metallic  than  the  tubular  breathing 
of  consolidation  or  cavity  formation.  Anteriorly  increased  vocal 
resonance  is  normal  over  the  manubrium.  With  swollen  glands 
anterior  to  the  trachea  and  bronchi,  whispered  bronchophony  is 
marked.  Fine  rales  are  sometimes  heard  external  to  the  hilus 
in  the  region  of  the  nipple,  usually  at  the  end  of  inspiration. 
They  are  not  removed  by  cough  or  deep  breathing.  Pressure  of 
the  nodes  on  the  trachea  may  cause  a  loud  stridor.  Loud  venous 
murmurs  may  be  audible,  probably  due  to  pressure  upon  the 
left  innominate  vein.  This  is  the  basis  of  Eustace  Smith's  sign  17 
which  is  elicited  as  follows. 


SIGNS  AND  SYMPTOMS  93 

Eustace  Smith's  Sign. — The  patient  is  seated  in  an  upright 
position  and  directed  to  extend  his  head  backward  upon  his 
shoulders  so  that  his  face  is  turned  upward.  With  the  stethoscope 
placed  upon  or  at  the  side  of  the  manubrium  sterni,  a  venous 
hum  is  heard  which  varies  in  intensity  according  to  the  size  and 
position  of  the  glands.  As  the  chin  is  slowly  depressed  again 
the  hum  becomes  less  distinctly  audible  and  ceases  shortly  before 
the  head  reaches  its  normal  position.  According  to  Smith,  the 
explanation  of  the  phenomenon  appears  to  be  that  the  retraction 
of  the  head  tilts  forward  the  lower  end  of  the  trachea.  This 
carries  with  it  the  glands  lying  in  its  bifurcation,  and  the  left 
innominate  vein  is  compressed  where  it  passes  behind  the  first 
bone  of  the  sternum.  He  believed  the  sign  to  be  very  reliable 
evidence  of  disease  and  enlargement  of  the  glands,  and  stated 
that  the  experiment  failed  in  healthy  individuals.  In  cases  of 
simple  flat  chest  and  enlarged  thymus,  the  latter  being  in  front 
of  the  vessels,  fixation  of  the  end  of  the  trachea  and  immobility 
of  the  glands  would  lead  to  failure  in  the  production  of  a  murmur. 
Opinions  vary  as  to  the  value  of  the  sign,  some  believing  it  to 
be  of  value,  and  others  as  unreliable.18'  19 

d'Espine's  Sign. — Some  years  ago  d'Espine  20  called  attention 
to  the  fact  that  in  children  whispered  bronchophony  normally 
ceased  at  the  level  of  the  seventh  cervical  vertebra,  but  that  in 
enlargement  of  the  bronchial  glands  it  extended  downward  to 
the  upper  thoracic  spines.  This  observation  has  since  been  known 
as  d'Espine's  sign  and  has  proven  to  be  a  reliable  factor  in  di- 
agnosing the  disease.  It  is  best  elicited  when  the  arms  are  folded 
well  across  the  chest,  the  head  sharply  flexed,  and  the  patient 
sitting  erect.  The  examiner  auscultates  posteriorly  over  the 
course  of  the  trachea  and  the  patient  is  asked  to  whisper  "three- 
thirty-three"  or  "one- two-three."  Young  children  can  be  more 
readily  induced  to  whisper  "tree"  or  other  familiar  words.  In 
positive  cases  the  final  "e"  of  the  last  word  persists  momentarily 
after  the  phonation  ceases.  This  post-phonal  quality  is  a  signif- 
icant feature.  The  whispered  voice  gives  more  satisfactory 
results  than  the  full  voice.  The  respiratory  murmur  is  the  least 
reliable  but  may  give  fair  results  in  experienced  hands  in  the  case 


94        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

of  infants  who  do  not  talk  or  cry.  Loud  transmission  of  the  vocal 
resonance  as  heard  over  the  normal  lung  does  not  constitute 
d'Espine's  sign.  The  transmitted  sound  must  have  tracheal 
timbre.  d'Espine's  observations  were  made  chiefly  on  infants 
and  children.  In  older  children  and  adults  the  bifurcation  of 
the  trachea  is  at  a  lower  level  than  in  the  infant  and,  for  this 
reason,  the  bronchophony  is  of  questionable  significance  unless 
heard  at  a  lower  level.  Opinions  differ  as  to  the  exact  point. 
FRAZIER  21  believes  the  sign  unreliable  unless  heard  below  the 
level  of  the  first  or  second  dorsal  in  a  child  of  eight,  and  below 
the  level  of  the  third  or  fourth  dorsal  in  a  child  of  twelve. 
MORSE  22  considers  the  sign  positive,  when  the  bronchial  sound 
extends  below  the  first  dorsal  spine.  Ho  WELL  23  accepts  as  a 
positive  d'Espine  a  change  in  the  character  of  the  whispered  voice 
or  expiration  at  or  below  the  second  dorsal. 

In  a  few  cases  did  he  find  the  change  as  high  as  the  seventh 
cervical,  and  frequently  as  low  as  the  third  dorsal  without 
cause.  FISHBERG  24  states  that  transmission  of  the  whispered 
voice  at  the  level  of  the  third  vertebra  in  a  child  of  ten  may  not 
mean  enlarged  glands  in  the  chest.  The  intensity  of  the  trans- 
mitted sound  varies  with  the  position  of  the  glands  and  the  de- 
gree of  their  enlargement.  Both  the  tracheal  and  hilus  glands, 
when  enlarged,  may  give  the  sign.  The  area  over  which  the 
whispered  bronchophony  is  heard  varies  greatly.  Sometimes  it 
is  limited  strictly  to  the  vertebral  spines  but  usually  it  extends  to 
one  or  both  sides.  STOLL  25  states  that  frequently  it  is  heard  as  far 
as  the  left  border  of  the  scapula,  and  quite  often  it  follows  the 
line  of  the  left  bronchus.  Its  import  is  increased,  when  heard  at 
one  or  both  sides  of  the  spine  as  well  as  over  the  spinous  proc- 
esses. 

Course  of  the  Disease. — The  signs  and  symptoms  as  above 
stated  may  be  almost  entirely  wanting  with  tuberculous  infection 
of  the  bronchial  glands.  When  present  they  are  variable  and 
may  appear  suddenly  and  remit  unaccountably.  Children  thus 
affected  "catch  cold"  easily  and  in  ordinary  cases  severe  symp- 
toms may  be  seen  only  at  such  times.  In  young  children  they 
may  then  become  alarming,  but  their  violence  usually  abates. 


§  •t3 


SIGNS  AND  SYMPTOMS  95 

Complications. — The  course  of  bronchial  node  disease  is 
chronic.  That  the  majority  of  the  glands  heal  is  evidenced  by 
the  finding  at  post-mortem  of  fibrous  and  calcified  remnants  of 
the  nodes  in  individuals  dying  from  old  age  or  intercurrent  dis- 
ease. The  presence  in  the  body  of  lesions  containing  virulent 
bacilli  is  a  constant  menace,  especially  in  children  under  five  years 
of  age.  In  them  tuberculous  processes  are  active  and  the  lesions 
progressive.  Simple  broncho-pneumonia  after  acute  infectious 
disease  may  become  converted  into  the  tuberculous  type.  Mil- 
iary  tuberculosis  of  the  lungs,  or  of  the  entire  body,  may  result 
from  the  bacilli  gaining  entrance  to  the  blood-stream.  Tuber- 
culous meningitis  is  common  in  children  and  the  tracheo-bronchial 
nodes  are  often  the  source  of  infection.  In  rare  instances,  the 
glands  may  soften  and  rupture  into  adjacent  organs.  Rupture 
into  the  trachea  gives  rise  to  severe  suffocative  attacks.  The 
alarming  dyspnoea  may  be  relieved  by  the  expectoration  of  a 
cheesy  mass,  or  the  attack  of  subsequent  ones  may  prove  fatal. 
Fatal  hemorrhages  into  the  air  passages  have  been  described. 
The  pleura  and  pericardium  may  be  involved  in  tuberculous  in- 
flammations. Rupture  into  the  oesophagus  is  an  uncommon 
event.  Traction  diverticulas  of  the  gullet  may  occur  from  ex- 
tension of  the  inflammation  from  the  glands,  with  adhesions  and 
subsequent  cicatricial  contraction. 

CERVICAL  GLANDS 

•  Tuberculosis  of  the  cervical  lymphatic  glands  is  more  readily 
recognized  than  disease  of  the  bronchial  nodes,  the  affected  glands 
being  more  superficially  located  and  permitting,  when  enlarged, 
of  palpation  and  inspection.  Of  the  external  glands  the  cervical 
are  most  often  affected  with  tuberculosis — 93%  of  WOHLGE- 
MUTH'S  cases  were  infected.26  In  TREVES'  27  series  of  155  cases 
they  were  involved  145  times,  and  the  only  seat  of  disease  in  131 
instances.  Tuberculous  adenopathy  of  these  glands  is  infrequent 
in  infancy.  It  is  most  commonly  observed  during  the  second 
decade,  but  is  not  infrequently  found  in  adults. 

Order  of  Group  Involvement. — The  glands  in  the  submaxillary 


96        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

triangle  and  those  of  the  superior  deep  cervical  group  located 
laterally  in  the  neck  along  the  carotid  artery  and  internal  jugular 
vein  are  the  most  frequent  sites  of  infection.  Less  commonly  the 
supra-clavicular,  occipital,  pre-auricular,  submental  and  parotid 
groups  are  affected.  Both  sides  of  the  neck  are  usually  involved, 
but  as  the  disease  progresses  the  more  advanced  changes  are 
confined  to  one  side  in  a  majority  of  cases. 

Slow  and  Painless  in  Development. — The  enlarged  nodes  are 
at  first  the  only  signs.  They  almost  always  develop  slowly  and 
painlessly  during  a  course  of  weeks  and  months.  They  are  first 
noted  as  indolent  lumps  apparently  incapable  of  further  change, 
appearing  first  in  front  of,  or  behind  the  Sternomastoid  muscle 
at  the  level  of  the  hyoid  bone  or  upper  border  of  the  larynx.  In 
rare  instances  the  onset  is  acute,  the  glands  enlarging  rapidly  with 
more  or  less  pain  and  temperature.  After  the  subsidence  of  the 
acute  symptoms  the  glandular  swelling  remains  and  may  suffer 
little  or  no  diminution  in  bulk.  The  enlargement  of  the  glands 
is  intermittent.  They  often  increase  for  a  time  and  then  remain 
stationary,  or  they  may  diminish  in  size.  They  may  take  a  new 
start  and  show  further  enlargement  following  inflammation  of 
the  associated  mucous  membranes,  acute  infections  such  as 
measles,  or  influenza,  or  simply  from  deterioration  of  the  general 
health.  As  the  condition  progresses  the  glands  may  become  as 
large  as  walnuts.  At  first  the  nodes  are  separate  and  discrete 
and  can  be  felt  as  individual  tumors  with  smooth  capsules  and  of 
firm  consistency.  Adjacent  glands  become  infected  until  an 
entire  region  is  involved  in  many  cases,  or  the  process  may  be 
confined  to  a  few  glands.  Eventually  they  become  adherent  to 
each  other  and  become  attached  to  adjacent  structures  by 
cicatricial  tissue  forming  irregular  knotted  masses  of  large  size 
in  which  it  may  be  difficult  to  make  out,  by  palpation,  the  in- 
dividual nodes.  The  course  is  chronic,  the  conditions  persisting 
for  months,  often  years.  The  enlargement  may  cease  at  any 
time,  become  latent  for  a  longer  or  shorter  period,  and  again  in- 
crease or  dwindle  and  disappear  spontaneously.  Eventually 
caseation  necrosis  occurs  and  later  softening. 

Suppuration.— HOLT  28  states  that  of  cases  allowed  to  run 


SIGNS  AND  SYMPTOMS  97 

their  course  probably  50%  terminate  in  suppuration.  This  is 
followed  by  inflammation  of  the  surrounding  tissues  and  the  skin 
finally  becomes  adherent.  The  abscess  may  be  limited  to  the 
gland  with  a  small  area  of  softening,  or  the  surrounding  tissues 
may  be  involved  with  more  extensive  inflammation.  Finally 
the  purulent  material  is  discharged  through  the  skin,  this  process 
being  repeated  with  the  softening  of  successive  glands.  The  pus 
is  thick  and  curdy  and  may  be  sterile  or  be  proven  to  be  tuber- 
culous by  animal  inoculation.  If  secondary  infection  has  oc- 
curred, the  pus  is  more  like  that  of  an  ordinary  abscess  and  the 
offending  organisms  can  be  demonstrated  by  culture.  Where 
abscesses  are  allowed  to  open  spontaneously,  large  irregular 
sinuses  and  ulcers  result,  the  condition  of  the  skin  referred  to  as 
scrofuloderma.  There  is  an  indolent  purplish  patch  of  skin 
which  is  pierced  by  one  or  two  sinuses  or  in  some  instances  is 
riddled  by  them.  The  skin  lesions  are  due  to  a  chronic  inflamma- 
tion surrounding  the  suppurating  tuberculous  focus.  There  may 
be  suppuration  of  the  skin  from  secondary  infection  with  pyogenic 
organisms,  and  in  rare  instances  there  may  be  tuberculous  ulcers 
of  the  skin  due  to  a  secondary  tuberculous  infection.  The  edges 
of  the  ulcers  are  undermined  and  ragged.  Beneath  the  skin  is 
an  indurated  mass  in  which  are  embedded  numerous  caseous  and 
purulent  glands. 

Sinuses  communicate  with  the  glands  by  a  narrow  opening, 
and  often  continue  to  discharge  for  many  weeks  and  months 
especially  when  the  general  condition  is  poor.  These  sinuses 
are  notoriously  chronic.  If  a  cicatrix  forms  before  the  gland  is 
completely  discharged  it  soon  breaks  down  again.  If  healing 
occurs  a  white,  puckered  disfiguring  scar  results,  as  is  so  often 
seen  about  the  neck.  But  suppuration  does  not  necessarily 
occur.  In  many  cases,  if  conditions  are  favorable,  the  glands 
gradually  diminish  in  size  and  return  to  normal  dimensions  or 
remain  as  small,  hard,  fibrous  nodules.  Calcification  of  the 
cervical  glands  rarely  occurs. 

Secondary  Infection. — Tuberculous  glands  are  subject  to 
secondary  infection,  especially  with  the  ordinary  pus-forming 
organisms,  which  leads  to  inflammatory  swelling  accompanied 


98        TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

by  pain  and  tenderness  and  the  general  signs  of  sepsis.  Moderate 
glandular  enlargement  is  not  incompatible  with  good  health 
in  other  respects,  but  if  the  disease  is  marked  the  nutrition  suffers. 
When  the  glands  are  large  and  active  there  is  fever.  These 
patients  are  usually  anaemic,  particularly  if  suppuration  is  of 
long  standing.  Tuberculous  cervical  glands  are  frequently  asso- 
ciated with  coryza,  rhinitis,  bronchitis,  eczema  of  the  scalp  and 
face,  conjunctivitis  or  keratitis,  etc.  The  eczema,  the  catarrhal 
inflammations  of  the  mucous  membranes,  plus  the  enlarged 
glands,  pallor  and  disturbed  nutrition,  constitute  the  picture 
formerly  known  as  scrofula  but  now  known  to  be  the  result  of  a 
tuberculous  process  and  its  associated  toxemia. 

Progress  Slow  and  Tedious. — The  progress  of  tuberculous 
cervical  adenitis  is  usually  slow  and  tedious.  Many  long  standing 
cases  recover.  There  is  a  tendency  for  the  inflammation  to  sub- 
side spontaneously  about  the  time  of  puberty,  and  cure  sometimes 
follows  intercurrent  illnesses  such  as  facial  erysipelas  or  scarlet 
fever.  Death  rarely  follows  but  may  occur  in  aggravated  cases 
from  sepsis,  exhaustion  and  amyloid  changes,  or  more  commonly 
from  tuberculosis  elsewhere,  as  in  the  lungs.  In  young  children 
these  glands  may  serve  as  the  source  of  a  generalized  infection. 

The  palatine  or  faucial  tonsil  has,  in  recent  years,  received 
marked  attention  for  the  r61e  it  plays  as  portal  of  entry  for  the 
tubercle  bacillus  in  cervical  adenitis.  Clinical  manifestations 
of  tuberculosis  of  the  tonsil  are,  as  a  rule,  entirely  missing.  The 
presence  of  a  tuberculous  tonsil  can  be  suspected  clinically  only 
by  its  effects,  namely,  infection  of  the  tonsillar  lymphatic  glands.29 
The  tonsils  may  be  hypertrophied,  small  and  submerged,  or  of 
medium  size. 

MESENTERIC  GLANDS 

Tuberculosis  of  the  mesenteric  and  retro-peritoneal  glands  was 
formerly  known  by  the  name  of  abdominal  scrofula  or  tabes 
mesenterica.  We  now  know  that  the  symptoms  included  by 
these  terms  were  due  more  to  the  associated  conditions  than  to 
the  infection  of  the  glands,  which  was  often  an  insignificant  part 
of  the  disease.  Pathologically  tuberculous  infection  of  these 


SIGNS  AND  SYMPTOMS  99 

nodes  is  common,  caseous  or  calcined  nodes  being  frequent  at 
autopsy  and  the  latter  often  being  found  in  Roentgen  examina- 
tion of  the  abdomen.  But  disease  of  these  nodes  of  itself  rarely 
causes  symptoms,  which  point  to  their  involvement,  and  unless 
there  are  complicating  conditions  it  may  pass  unnoticed  or  be 
discovered  at  operation  for  other  conditions. 

Usually  a  Secondary  Infection.— The  glands  are  most  com- 
monly infected  secondarily  to  tuberculosis  of  the  intestines. 
However,  they  may  be  primarily  infected,  as  it  has  been  demon- 
strated experimentally  in  animals,  and  clinical  experience  often 
supports  the  view,  that  tubercle  bacilli  can  pass  through  the 
intestinal  mucous  membrane  without  producing  a  lesion  there, 
and  infect  the  adjacent  nodes.  Such  infection  is  analogous  to 
that  of  the  cervical  nodes  which  may  be  infected  without  ev- 
idence of  a  tuberculous  process  in  their  tributary  mucous  mem- 
brane. Although  found  most  commonly  in  children  it  is  not 
confined  to  them  and  may  occur  in  adults  as  well,  infection  fre- 
quently occurring  from  swallowed  sputum,  in  those  who  are 
suffering  from  a  pulmonary  tuberculosis.  The  infected  glands 
become  enlarged  ordinarily  from  one-half  to  one  inch  in  diameter. 
A  number  of  the  glands  may  become  fused  together,  forming 
masses  of  considerable  size.  Caseation  is  the  usual  termination 
of  the  glands;  less  frequently  they  become  calcined  and  rarely 
they  suppurate. 

Often  no  Characteristic  Symptoms. — Except  when  the  glands 
form  masses  large  enough  to  be  palpable,  there  are  no  symptoms 
which  are  characteristic  or  distinctive  of  their  tuberculous  in- 
fection. Slight  enlargement  may  be  consistent  with  good  health. 
If  they  remain  as  the  sole  lesion  the  individual's  nutrition  may 
remain  good,  his  temperature  normal,  and  slight  pallor  of  the 
face  be  the  only  indication  of  ill  health.  In  some  cases  there  are 
no  symptoms  even  with  the  presence  of  palpable  glands.  When 
there  are  such  symptoms  as  wasting,  diarrhoea,  night  sweats  and 
increased  temperature,  they  are  probably  due  more  to  other 
tuberculous  lesions  than  to  the  glandular  involvement.  With 
intestinal  involvement  the  condition  is  more  serious  and  the 
symptoms  may  be  severe.  With  ulceration  there  are  repeated 


ioo      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM. 

attacks  of  diarrhoea  with  profuse,  foetid,  watery  stools,  often 
containing  blood.  The  severity  of  the  diarrhoea  depends  on  the 
extent  of  ulceration. 

Metabolism  Impaired. — Intestinal  absorption  is  greatly  di- 
minished with  resultant  loss  of  weight,  emaciation  and  a  co- 
incident loss  in  strength.  The  child  becomes  pale  and  anaemic, 
the  skin  dry  and  wrinkled.  The  temperature  is  increased  above 
normal.  The  rise  is  usually  periodical  and  more  or  less  in  propor- 
tion to  the  degree  of  intestinal  irritation.  The  intestines  are 
often  distended  with  gas  and  the  abdomen  tympanitic.  The 
abdominal  wall  becomes  thinned  and  softened  and  tender  to  the 
touch.  In  a  considerable  number  of  cases  the  peritoneum  be- 
comes involved.  In  the  miliary  type  of  tuberculous  peritonitis, 
there  is  gradual  loss  of  weight  and  strength  and  the  abdomen 
slowly  becomes  distended  with  fluid.  In  the  ulcerative  and 
fibrous  types,  there  is  a  lesser  amount  of  fluid  and  in  addition 
adhesions  which  bind  together  the  glands,  intestines  and  omen- 
turn.  The  abdomen  becomes  distended,  on  palpation  it  is  tender 
and  firm,  and  large  nodular  masses  of  glands  or  adherent  intes- 
tines and  omentum  may  be  felt.  On  percussion  checker  board 
dulness  may  be  elicited;  this  is  a  very  valuable  diagnostic  sign. 
Intestinal  obstructions  or  fecal  fistulse  may  result. 

Localized  Involvement  Stimulating  Appendicitis. — The  glands 
in  the  ileocaecal  region  may  alone  be  involved  and  give  rise  to 
symptoms  simulating  appendicitis.  There  may  be  tuberculosis 
of  the  appendix  and  caecum,  or  the  glands  may  be  infected  pri- 
marily. An  analogy  is  to  be  noted  between  the  infection  of  the 
glands  adjacent  to  the  appendix  and  infection  of  the  cervical 
glands  adjacent  to  the  palatine  tonsil.  The  appendix  is  a  lym- 
phoid  structure  and  has  been  called  the  abdominal  tonsil.  In 
such  cases  abdominal  pain  having  an  acute  onset,  accompanied 
by  nausea  and  sometimes  by  vomiting,  may  become  localized 
in  the  right  iliac  fossa.  Local  examination  reveals  tenderness 
and  rigidity  of  the  abdominal  muscles  but  a  tumor  mass  is  rarely 
palpable.  There  may  be  repeated  attacks  of  such  pain,  simulating 
very  closely  appendicitis.  Although  it  may  appear  to  be  some- 
what atypical  of  appendicitis,  unless  the  patient  shows  well- 


SIGNS  AND  SYMPTOMS  101 

marked  evidence  of  tuberculosis,  a  differential  diagnosis  may  be 
impossible  until  the  abdomen  is  opened  at  operation.  Such 
cases  have  been  reported  by  GAGE,  EISENDRATH,  PARKER  and 
others. 

Local  Manifestations. — Many  cases  of  tuberculosis  of  the 
mesenteric  glands  show  dilatation  of  the  superficial  veins  of  the 
abdominal  wall.  In  exceptional  cases  the  glands  may  be  large 
enough  to  press  upon  surrounding  structures.  Pressure  on  the 
vena  cava  may  cause  oedema  of  the  legs.  Ascites  may  be  due 
to  enlarged  glands  in  the  hilus  of  the  liver  with  pressure  upon 
the  portal  vein.  Pressure  on  the  nerves  may  result  in  cramp- 
like  pain  in  the  lower  limbs.  Unless  they  are  considerably  en- 
larged the  mesenteric  glands  are  not  palpable,  when  sufficiently 
enlarged  they  may  be  felt  on  deep  palpation  as  irregular  masses 
at  the  sides  of  the  spine  at  about  the  level  of  the  umbilicus. 
Enlarged  glands  may  occasionally  be  reached  by  rectal  palpation. 

Softening  of  the  glands  is  infrequent.  When  it  occurs  it  may 
lead  to  a  localized  abscess  among  the  intestinal  coils,  or  may 
ulcerate  into  the  intestines.  Of  the  uncomplicated  cases,  per- 
haps a  certain  and  not  small  proportion  recover  under  suitable 
treatment,  even  when  the  glands  were  large  enough  to  palpate. 
In  such  cases  recovery  depends  largely  on  the  treatment.  With 
complications  the  course  is  downward,  with  intestinal  ulceration, 
diarrhoea  and  wasting,  or  more  often  by  an  outbreak  of  tuber- 
culosis elsewhere,  as  a  meningitis  or  miliary  tuberculosis. 

TUBERCULOSIS  OF  OTHER  LYMPHATIC  GLANDS 

Frequency. — Lymphatic  glands  of  the  body,  other  than  the 
bronchial,  cervical  and  mesenteric,  are  less  often  infected  with 
tuberculosis,  as  is  to  be  expected,  on  account  of  diminished  ex- 
posure. The  following  statistics  are  indicative  of  the  frequency 
of  their  involvement: — 30 


102 


Balmann's  Wohlgemuth's 

findings  findings 

Neck  and  occipitaf  81     %  93     % 

Axillary  6.0  %  2.78% 

Inguinal  7-°  %  -93% 

Popliteal  .07%  -23% 

Cubital  5-o  %  .23% 

Auricular  2.9  % 

The  Axillary  Glands,  from  eight  to  ten,  to  fifteen  or  more  in 
number,  are  situated  in  the  axillary  space  and  drain  the  mammary 
region  and  side  of  the  thorax,  both  the  superficial  and  deep  areas. 
Although  less  frequently  observed  than  cervical  node  involve- 
ment, tuberculous  infection  of  these  glands  is  by  no  means  rare. 
Not  infrequently  they  are  infected  in  connection  with  the  cervical 
glands.  The  most  common  sources  of  infection  are  tuberculous 
lesions  of  the  arm  and  hand,  tuberculosis  verrucosa  cutis,  or 
anatomical  wart,  received  through  injury  at  autopsy  or  other- 
wise, and  tuberculosis  of  the  mammary  gland.  The  glands  may 
not  be  affected  in  the  former  conditions,  but  they  generally 
are  found  to  be  involved  in  tuberculosis  of  the  mammary  gland. 
The  diseased  nodes  are  felt  as  firm  movable  nodules  in  the  soft 
tissues  of  the  axilla.  They  may  reach  the  size  of  walnuts,  but 
they  do  not  often  lead  to  the  formation  of  abscesses  and  sinuses. 

The  Cubital  Glands  are  not  invariably  involved  in  infections 
of  the  hand  and  fingers,  but  tend  to  become  infected  in  deep 
processes.  They  may,  in  such  instances,  be  diseased  in  conjunc- 
tion with  the  axillary  glands,  or  be  alone  infected. 

The  Inguinal  Glands. — Tuberculous  infection  of  the  inguinal 
glands,  although  far  from  common,  is  more  frequent  than  is 
generally  recognized.  The  infection  may  be  derived  from  several 
sources  and  the  primary  focus  may  not  be  evident.  It  is  not  in- 
frequent in  connection  with  tuberculous  lesions  of  the  genitalia 
about  the  anus  or  within  the  pelvis.  HOLT  31  and  others  have 
reported  cases  of  tuberculous  inguinal  adenitis  following  cir- 
cumcision, the  wound  being  infected  by  the  operator.  Tuber- 
culous ulcers  resulting  from  wounds  of  the  feet  may  be  the  source 
of  infection.  DOWD  32  has  reported  such  cases. 

The  infection  attacks  both  the  deep  and  superficial  glands. 


SIGNS  AND  SYMPTOMS  103 

The  femoral  nodes  in  Scarpa's  triangle  and  the  inguinal  groups 
along  Poupart's  ligament  become  involved  and  the  infection 
exhibits  a  tendency  to  spread  upward  into  the  pelvis,  through 
the  lymphatic  structures,  surrounding  the  iliac  vessels.  Involve- 
ment of  the  nodes  may  be  rapid  or  slow,  and  the  infection  viru- 
lent or  very  mild. 

The  Popliteal  Glands  are  rarely  involved  in  a  tuberculous  in- 
fection and  when  observed  it  is  secondary  to  infection  of  wounds 
of  the  feet. 

GENERALIZED  TUBERCULOUS  ADENITIS 

A  rare  occurrence  is  a  tuberculosis  of  nearly  all  the  lymph- 
glands  of  the  body  with  little  or  no  involvement  of  other  parts. 
It  occurs  more  often  in  negro  patients  and  in  connection  with 
pulmonary  tuberculosis.  It  is  usually  accompanied  by  a  tem- 
perature of  101  to  103°  F.  and  the  course  of  the  disease  is  often 
rapidly  fatal.  Any  or  all  of  the  superficial  gland  groups,  cervical, 
axillary,  or  inguinal,  may  be  involved.  The  glands  are  firm  and 
caseous  and  may  be  greatly  enlarged.  There  is  often  extensive 
involvement  of  the  bronchial,  mesenteric  and  retro-peritoneal 
glands.  There  may  or  may  not  be  active  tuberculous  lesions 
elsewhere. 

Differentiation  from  Hodgkin's  Disease. — The  more  acute 
cases  resemble  Hodgkin's  disease  very  closely.  In  infants  and 
children  the  infection  may  involve  various  groups  of  glands  in 
succession,  more  rarely  simultaneously.  Such  cases  are  usually 
fatal,  death  being  due  to  a  meningeal  infection,  or  cachexia,  and 
exhaustion.33 

TUBERCULOUS  LYMPHANGITIS 

Tuberculous  lymphangitis  is  a  rare  occurrence,  if  we  exclude 
those  cases  in  which  mesenteric  lymphatic  vessels  are  involved 
in  connection  with  a  tuberculosis  of  the  intestines,  and  can  be 
traced  through  the  mesentery  to  the  receptaculum  chyli,  and 
the  involvement  of  the  thoracic  duct  in  miliary  tuberculosis. 
In  rare  instances  tuberculous  lymphangitis  develops  in  the  ex- 


104      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

tremities,  more  often  in  the  upper,  in  connection  with  tuber- 
culous lesions  of  the  fingers,  such  as  tuberculous  ulcers  or  sinuses, 
which  have  followed  the  rupture  of  an  osteal  focus. 

The  Lymphatic  Vessels. — Small  firm  nodules  develop  along 
the  course  of  the  lymphatic  vessels.  When  numerous  they  may 
form  a  cord-like  infiltration.  The  nodules  slowly  increase  in 
size  and  may  undergo  caseation  and  softening  and  discharge 
externally  leaving  ulcers  and  fistulae.  A  provisional  diagnosis 
of  tuberculosis  of  the  deep  lymphatic  vessels  may  be  made  if  an 
abscess,  which  has  no  connection  with  bone  or  joint,  develops 
in  the  course  of  the  large  lymphatic  vessels.34 


CHAPTER  VII 
PROGNOSIS 

The  progress  of  tuberculosis  of  the  lymphatic  system  depends 
upon  many  factors,  the  most  important  of  which  are  the  extent 
of  involvement,  resistance  to  infection,  virulence  of  same,  and 
age  of  patient.  Many  other  factors,  of  course,  have  a  bearing 
on  the  question,  for  instance,  the  social  position  which  still  plays 
quite  an  important  r61e  in  determining  the  sentence  of  life  or 
death  amongst  our  infants. 

Any  factor  that  tends  to  lower  the  resistance  of  the  patient 
ought  to  be  considered  when  prognosticating  a  tuberculous  con- 
dition. Lack  of  proper  food,  unhygienic  surroundings,  and  mal- 
nutrition have  a  decidedly  unfavorable  influence  upon  the  course 
of  tuberculosis.  The  importance  of  these  factors  can  never  be 
overestimated. 

The  age  of  the  patient  is  undoubtedly  the  most  predominating 
factor  from  the  standpoint  of  prognosis.  The  younger  the  child, 
the  graver  the  outlook.  If  a  child  can  be  protected  from  a 
massive  infection  up  to  7  or  8  years  his  chances  for  life  are  very 
much  improved. 

The  virulence  of  infection  determines  to  a  large  extent  the 
course  of  the  disease.  Bovine  infection  is,  as  a  rule,  mild  in  its 
course  and  yields  readily  to  proper  care.  The  virulence  of  the 
human  type  bacillus  varies  markedly  from  a  very  mild  affair  to 
the  fulminating  types. 

The  extent  of  involvement  and  regions  involved  are  apparent  in 
their  importance.  The  more  extensive  the  involvement,  the 
worse  the  prognosis,  and  the  more  vital  regions  involved,  the 
more  dangerous  the  condition.  Bronchial  gland  tuberculosis 
is  more  serious  than  mesenteric  glandular  involvement  and 
cervical  adenitis. 


io6      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

Bronchial  Gland  Tuberculosis.— The  prognosis  in  this  con- 
dition is  always  serious  but  far  from  fatal.  The  majority  of 
children  having  infection  of  the  bronchial  glands  recover,  when 
they  are  placed  in  good  surroundings  and  treated  properly.  The 
younger  the  child,  the  more  grave  the  prognosis.  Involvement 
of  the  bronchial  glands  in  babies  under  one  year  usually  means 
death;  between  one  and  two  years  recoveries  are  less  exceptional. 
From  three  on  the  prognosis  is  more  and  more  favorable.  Obser- 
vation teaches  us,  says  HuxiNEL,1  that  the  majority  of  children 
carried  away  by  miliary  tuberculosis  (meningitis)  have  caseous 
foci  in  their  bronchial  glands,  and  the  softening  of  these  foci 
seems  often  to  have  been  the  cause  of  the  final  explosion. 

As  the  child  grows  older  the  frequency  of  latent  tuberculosis 
increases  and  chances  for  recovery  are  now  much  better  if  cor- 
rectly treated.  But  there  is  one  more  period  of  life  that  is  quite 
important  and  acquires  its  annual  toll,  namely,  the  period  of 
adolescence.  Boys  between  17  and  20,  and  girls  from  14  to  16, 
often  fall  an  easy  prey  for  the  enemy  trenched  in  amongst  the 
bronchial  glands. 

The  size  of  the  lesion  will  not  lend  itself  to  prognostication 
because  the  gravity  of  the  condition  is  independent  of  the  size 
of  the  glands.  Large  masses  may  recede,  sclerose  and  heal  up, 
while  the  small  active  foci  may  be  the  cause  of  rapidly  fatal 
complications,  especially  meningitis. 

The  presence  of  pulmonary  lesions  in  active  state  have  an 
important  bearing  upon  the  question  of  prognosis.  Modern 
pathology  teaches  us  that  the  great  majority  of  cases  of  hilus 
tuberculosis  is  due  to  a  pulmonary  infection,  the  focus,  however, 
often  being  so  small  that  a  painstaking  search  is  required  to  find 
the  same.  A  great  many  of  these  youngsters  succumb  to  the 
first  attack,  a  certain  number  rally,  however,  having  the  hilus 
infection  as  a  remembrance  of  their  former  struggle.  A  secondary 
infection  of  the  lungs  now,  from  the  bronchial  gland  focus,  con- 
stitutes most  probably  the  ordinary  type  of  adult  tuberculosis. 
The  younger  in  life  it  occurs  the  correspondingly  graver  is  the 
situation. 

Several  intercurrent  diseases  manifestly  play  an  important  r61e 


PROGNOSIS  107 

in  awaking  latent  foci  of  bronchial  gland  tuberculosis.  Measles 
and  whooping  cough  are  universally  known  often  to  be  followed 
by  manifestations  of  active  tuberculosis.  Many  children  having 
weathered  successfully  the  acute  infections  succumb  to  a  tuber- 
culous complication,  e.  g.,  meningitis.  Post-mortem  examinations 
in  these  cases  often  reveal  softened  caseous  foci  in  the  bronchial 
glands.  The  modus  operandi  in  these  cases  is  self-evident.  The 
bronchial  infection  always  present  in  measles  and  whooping 
cough  overtaxes  the  diseased  lymphatic  system  of  the  lungs. 
The  walled-off  focus  becomes  suddenly  the  seat  of  pronounced 
inflammatory  changes,  the  localized  tuberculous  lesion  becomes 
disseminated,  parts  of  the  same  may  enter  the  blood-stream,  and 
a  miliary  tuberculosis  result. 

Mesenteric  Gland  Tuberculosis. — Simple  involvement  of  the 
mesenteric  glands,  without  any  intestinal  complications,  is  not  a 
very  serious  matter.  Most  of  these  cases  recover  under  proper 
management. 

Complications,  however,  may  change  the  entire  outlook. 
Rupture  of  an  enlarged  gland  causes  tuberculous  peritonitis 
which  may,  however,  under  favorable  conditions  go  on  to  re- 
covery. 

Tuberculous  ulcers  of  the  intestine,  as  a  rule  secondary  to 
pulmonary  tuberculosis,  often  represent  the  last  stages  of  the 
disease.  Sometimes  these  patients  may  be  kept  alive  for  a  year 
or  two,  but  this  is,  as  a  rule,  a  sorrowful  existence  due  to  the 
marked  diarrhoea  and  subsequent  emaciation. 

Tuberculous  Cervical  Adenitis. — Tuberculosis  of  the  external 
lymphatic  glands  per  se  may  have  a  fatal  outcome.  Secondary 
infections  may  produce  a  marked  toxic  condition  due  to  the 
prolonged  suppuration  which,  together  with  poor  resistance 
and  malnutrition,  may  cause  death.  But  tuberculous  cervical 
adenitis  is,  as  a  rule,  called  to  our  attention  before  such  a  con- 
dition exists,  and  nearly  all  these  cases  will  respond  to  proper 
treatment. 

When  suppuration  and  sinuses  are  already  present  the  progno- 
sis of  complete  recovery  must  be  somewhat  guarded.  But 
wonderful  results  are  obtained  at  the  present  time  under  proper 


io8      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

management.  Tuberculin  and  X-Ray  stand  forth  as  the  most 
important  remedial  agents.  Personally,  I  have  by  means  of 
tuberculin  caused  many  tuberculous  sinuses  to  heal  with  only 
slight  scar  formation. 

The  rational  use  of  tuberculin  has  a  marked  influence  upon 
the  prognosis  of  tuberculous  lymphadenitis.  Our  experience 
coincides  with  that  of  BANDELIER  and  ROEPKE  in  that  we  have 
never  seen  a  gland  break  down  under  tuberculin  treatment. 
Similar  results  have  been  obtained  by  many  men.  It  seems  to 
the  author  that  a  remedy,  which  in  the  hands  of  many  different 
men  has  met  with  so  wonderful  success  should,  at  least,  get  part 
of  the  recognition  it  deserves  from  the  profession  at  large. 


CHAPTER  VIII 

DIAGNOSIS 

CLINICAL  DIAGNOSIS 

Tuberculosis  of  the  Bronchial  Glands. — The  clinical  picture  of 
tuberculosis  of  the  bronchial  glands  is  by  no  means  distinct, 
and  rarely  is  the  entire  symptom  complex  present  and  pointing 
to  the  diagnosis.  The  early  symptoms  especially  are  indefinite. 
The  recognition  of  physical  signs  of  disease  of  these  glands  is 
difficult,  and  often  unsatisfactory  because  of  their  situation  deep 
within  the  chest.  In  the  early  stages  there  may  be  no  physical 
signs  although  the  disease  is  active.  In  attempting  to  make  a 
diagnosis,  therefore,  no  line  of  investigation  should  be  omitted 
and  all  possible  information  which  might  be  of  value  obtained. 

Importance  of  Care  in  Taking  History. — A  history  should  be 
carefully  taken  as  it  may  give  important  data.  Inquiry  is  made 
as  to  the  existence  of  tuberculous  disease  in  the  parents,  or  in 
other  children  in  the  family,  or  in  associates,  with  whom  the 
patient  comes  in  close  and  frequent  contact.  The  presence  of 
tuberculous  disease  in  the  parents  does  not,  as  was  formerly 
supposed,  point  to  hereditary  predisposition  or  predestination 
to  tuberculosis  in  the  child,  but  is  of  great  importance  since  it 
serves  as  a  source  of  infection.  It  is  during  early  life  that  con- 
tact between  children  and  their  parents  or  associates  is  closest, 
and  it  is  at  this  time  that  susceptibility  to  infection  is  greatest. 
Inquiry  should  be  made  as  to  the  occurrence  of  previous  diseases, 
and  especially  concerning  a  recent  attack  of  measles,  whooping 
cough  or  influenza.  An  allergic  state  occurs  in  such  conditions 
as  is  demonstrable  by  the  negative  v.  Pirquet  test  in  children  in 
whom  it  had  previously  been  positive.  These  diseases  are  im- 
portant in  that  they  may  be  the  etiological  factors  in  the  activa- 
tion of  a  previously  latent  infection.  A  prolonged  and  unsat- 


no 


TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 


isfactory  convalescence  from  such  disease  should  always  lead  one 
to  think  of  tuberculosis. 

Insidious  Onset. — In  discussing  symptoms,  I  called  attention 
to  those  symptoms  and  signs  constituting  the  general  picture  of 
the  disease.  These  are  in  large  part  toxic  in  origin  and  must  not 
be  overlooked.  The  insidious  onset,  with  feeling  of  languor 
and  fatigue,  the  anorexia  or  capricious  appetite,  the  neurasthenic 
symptoms,  the  loss  of  weight  and  impaired  nutrition,  the  pallor, 
the  slight  rise  in  temperature,  are  all  general  symptoms  observed 
in  early  tuberculosis. 

But  any  or  all  of  these  symptoms  may  be  present  from  causes 
other  than  tuberculosis.  Bearing  this  in  mind  other  factors 
should  be  excluded.  Thus  anaemia,  fatigue  and  malaise  are 
symptoms  which  may  result  from  overwork  in  school,  late  hours, 
lack  of  fresh  air,  digestive  disturbances,  and  other  conditions, 
as  well  as  from  tuberculosis. 

Temperature. — Too  much  attention  must  not  be  attached  to 
a  slight  rise  in  temperature  in  children,  for  in  childhood  it  is  a 
frequent  occurrence  from  such  causes  as  infection  of  the  naso- 
pharynx or  accessory  sinuses,  pyelitis  or  digestive  disturbances. 
Such  things  should  be  thought  of  and  eliminated. 

Cough  and  Dyspnoea. — A  dry  cough  may  be  due  to  naso- 
pharyngeal  irritation  or  enlargement  of  the  lingual  tonsils.  The 
cough  in  tuberculosis  of  the  bronchial  nodes  resembles  closely 
that  of  pertussis.  The  latter,  however,  more  often  shows  nightly 
exacerbations  and  the  paroxysms  are  more  frequently  accom- 
panied by  vomiting  or  the  expectoration  of  mucus.  If  these 
conditions  can  be  excluded  the  cough  is  quite  diagnostic.  The 
dyspnoea  frequently  observed,  when  there  is  pressure  on  the 
bronchi  or  trachea,  resembles  that  of  laryngeal  croup  except  that 
the  voice  is  not  lost. 

Asthmatic  attacks  in  children  should  always  lead  to  suspicion 
of  bronchial  node  tuberculosis. 

Spinalgia. — The  spinalgia  described  by  PETRUSCHKY  is  present 
with  active  inflammation,  but  is  not  found  with  cheesy  nodes. 
The  tenderness  may  be  slight  or  very  acute,  and  unless  definite 
it  is  of  no  value.  To  judge  the  degree  of  tenderness  note  the 


DIAGNOSIS  in 

facial  expression  while  palpating  over  the  spine.  De  La  CAMP 
noted  this  sign  in  87%  of  100  incipient  cases.  The  spinalgia 
disappears  with  rest  in  bed  and  tuberculin.  Cardiac  disease 
should  be  eliminated,  as  spinal  tenderness  may  occur  with  it. 
The  tenderness  noted  in  neurasthenia,  in  contradistinction  to 
that  of  tuberculosis  of  the  tracheo-bronchial  nodes,  is  not  limited 
to  the  upper  thoracic  vertebrae. 

Spinal  Dulness. — On  percussion  of  the  vertebral  spines  from 
above  downward  the  sound  is  dull  and  the  tactile  resistance 
exaggerated  over  the  upper  three  or  four  dorsal  vertebras,  below 
which  level  the  remaining  thoracic  spines  afford  low  pitched 
resonance  with  a  distinct  osteal  quality.  Dulness  extending 
down  to  or  below  the  fifth  or  sixth  dorsal  vertebra  is  pathologic. 
This  may  be  due  to  bronchial  glands,  when  they  are  consider- 
ably enlarged.  Aneurism  of  the  aorta,  mediastinal  neoplasm, 
consolidation  of  the  lung,  pleural  effusion  and  a  dilated  heart 
may  cause  spinal  dulness,  and  should  be  thought  of,  and 
ruled  out  as  possible  causes  when  diagnosing  glandular  en- 
largement. 

d'Espine's  Sign. — I  consider  d'EspiNE's  sign  of  great  value 
in  diagnosis.  The  transmission  of  the  whispered  voice  indicates 
that  some  tissue,  denser  than  normal,  is  present  between  the 
trachea  and  bronchi  and  the  anterior  surface  of  the  vertebral 
column,  which  transmits  the  sound  without  modification. 
While  it  shows  nothing  as  to  the  character  of  the  tissue,  experience 
shows  that  it  is  usually  glands.  A  positive  d'EsriNE  sign  has  a 
great  value.  When  it  is  negative  it  must  be  remembered  that 
tuberculous  glands  may  be  present,  but  not  enlarged  to  a  sufficient 
extent,  or  so  situated  as  to  be  interposed  between  the  trachea, 
bronchi  and  the  vertebral  column.  The  sign  is  regarded  as  of 
value  by  STOLL,  DAUTWITZ,  SMITH,  BACH  and  others.  While 
the  control  of  the  sign  by  autopsy  has  not  been  large,  cases  have 
been  observed  by  d'EspiNE,  STOLL  and  others.  I  consider 
EUSTACE  SMITH'S  sign  of  little  value. 

Neisser's  Pressure  Method. — NEISSER  proposed  to  test  the 
sensitiveness  of  pressure  of  tuberculous  bronchial  glands  by 
means  of  a  distensible  sound  introduced  into  the  oesophagus. 


ii2      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

He  made  use  of  a  hollow  sound  with  a  rubber  finger  cot  tied  over 
the  fenestra.  By  means  of  a  rubber  bulb  this  could  be  inflated 
at  various  levels  and  pressure  thus  exerted  on  the  glands  from 
within  the  oesophagus.  Tenderness  was  elicited  in  cases  of  tuber- 
culous glands,  while  healthy  individuals  were  free  from  pain. 
Though  ingenious,  the  method  is  little  used. 

Tracheo-Bronchoscopy. — In  some  cases  tracheo-bronchoscopy 
has  been  made  use  of.  The  bulging  of  enlarged  glands,  lying 
near  to  the  trachea  and  bronchi,  may  be  recognized.  Because 
of  the  difficulty  encountered  in  diagnosing  tuberculosis  of  bron- 
chial glands,  all  signs  and  symptoms  should  be  looked  for.  A 
single  sign  or  symptom  cannot  make  a  diagnosis.  "The  presence 
of  dilated  veins,  spinalgia,  dullness  and  d'Espine's  sign,  speaks  for 
enlarged  glands."  Their  tuberculous  nature  is  practically 
assured  when,  in  addition  to  these,  the  individual  is  under  weight, 
has  a  paroxysmal  cough  and  symptoms  of  toxemia. 

X-Ray. — The  use  of  the  X-ray  in  the  diagnosis  of  tuberculosis 
of  the  bronchial  glands,  is  of  considerable  value.  Enlarged  and 
pathological  glands  can  often  be  demonstrated  by  this  means, 
when  the  symptoms  are  general  and  vague,  and  the  local  symp- 
toms and  physical  signs  are  altogether  wanting.  The  X-ray  may 
show  gland  involvement,  when  they  have  not  yet  reached  suffi- 
cient size  to  cause  cough,  dyspnoea  or  other  pressure  symptoms, 
and  when  they  are  too  small  to  cause  a  d'EspiNE's  sign  or 
appreciable  dulness.  Studies  of  the  X-ray,  percussion,  or 
d'EspiNE's  sign,  show  them  to  be  of  about  equal  diagnostic 
value. 

Steroscopic  Plates. — In  the  examination  of  the  chest  by  means 
of  the  X-ray,  we  may  use  the  fluoroscope,  a  single  plate,  or  the 
steroscopic  plates.  The  latter  are  always  preferable,  since  they 
show  the  shadows  in  perspective,  and  enable  the  observer  to 
appreciate  the  third  dimension,  and  the  depth  of  the  lesions  from 
the  surface  of  the  chest.  Shadows  are  visible  hi  steroscopic 
plates,  which  are  not  in  single  plates,  in  which  they  are  super- 
imposed. While  the  fluoroscopic  method  of  examination  is  of 
great  value,  the  plate  method  is  preferable.  In  an  X-ray  plate, 
we  have  a  permanent  graphic  record  of  the  varying  density  of 


DIAGNOSIS  113 

the  tissue  through  which  the  rays  have  passed.  The  fluoroscope, 
on  the  other  hand,  is  an  observation  but  not  a  record,  and  gives 
us  nothing  tangible  for  further  study  or  comparison. 

Normal  Findings. — In  the  radiograms  of  a  normal  chest  the 
bony  skeleton  with  its  covering  of  soft  parts  stands  out  plainly, 
the  ribs  bounding  the  chest  on  all  sides,  except  the  narrow 
inlet  above,  and  below  where  we  have  the  diaphragm.  Within 
the  chest  several  groups  of  shadows  may  be  seen  and  are  de- 
scribed as  the  central  opacity  or  shadow,  the  hilus  shadow, 
and  the  markings  in  the  lung  fields. 

Interpretation  of  Radiograms.— The  central  shadow  is  large 
in  size  and  distinct.  It  is  made  up  of  the  shadows  cast  by  the 
vertebral  column  and  the  mediastinal  contents,  consisting  of 
the  heart,  aorta,  and  other  great  vessels,  oesophagus,  trachea, 
lymphatics,  and  connective  tissue.  The  trachea  can  often  be 
distinguished,  as  a  light  band  bounded  on  either  side  by  darker 
bands,  and  its  bifurcation  at  the  level  of  the  fifth  dorsal  may  be 
visible. 

The  Hilus  Shadow. — The  hilus  shadow  is  noted  at  the  level 
of  the  fifth,  sixth  and  seventh  dorsal  vertebrae.  Normally  it  is  of 
moderate  density,  of  small  extent  and  irregular  in  outline.  It 
is  caused  by  the  density  of  the  primary  bronchi,  the  pulmonary 
vessels  and  their  contained  blood,  and  the  lymphatic  and  fibrous 
tissues  of  the  hilus  of  the  lung.  Toward  the  median  line  it  merges 
with  the  heart  shadow,  but  on  the  right  it  is  distinctly  seen  ex- 
tending outward  into  the  lung  field.  The  outer  margin  of  the 
hilus  shadow  is  irregular,  because  of  the  shadow  cast  by  the 
bronchial,  and  vascular  trunks  extending  outward  from  the  hilus 
into  the  parenchyma  of  the  lung. 

Lung  Markings. — In  the  lung  fields  we  find  the  linear  markings; 
near  the  hilus  they  are  heavier  and  more  distinct  than  toward 
the  periphery.  In  some  plates  the  shadows  may  be  seen  in 
groups  corresponding  roughly  to  the  lobes  of  the  lungs  as  the 
shadows  extend  toward,  but  not  quite  to  the  periphery  of  the 
lungs.  These  markings  are,  like  the  hilus  shadows,  made  up  of 
the  shadows  cast  by  the  divisions  of  the  bronchi,  the  blood-vessels 
and  their  contained  blood,  together  with  the  accompanying 


ii4      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

lymphatic  vessels  and  fibrous  tissue.  The  intensity  of  the  mark- 
ings is  greater  in  adults  than  in  children. 

Early  Tuberculous  Changes  are  noted  by  an  increase  hi  the 
area  and  density  of  the  hilus  shadows.  These  changes  are  due 
to  an  increase  hi  the  fibrous  and  lymphatic  tissue  which  accom- 
panies a  mediastinitis.  But  such  changes  may  be  caused  by  in- 
fections other  than  tuberculosis.  The  finer  markings  may  be 
more  prominent  and  appear  broader,  denser  and  extend  closer 
to  the  periphery  of  the  lung.  The  lines  may  be  studded,  or 
broken  in  continuity  and  show  a  delicate  network. 

Normal  Glands  Cast  no  Shadow. — In  early  involvement  the 
individual  glands  may  not  be  seen,  the  only  thing  noted  being  an 
increase  in  the  width  of  the  lung  root.  When  the  glands  become 
caseous  they  appear  as  more  or  less  shadowy  spots.  Calcified 
glands  are  sharply  defined  and  easily  recognized.  When  a  large 
mass  of  nodes  is  present  a  distinct  lobulated  mass  may  be  seen. 
Shadows  can  be  diagnosed  as  glands  only  when  they  are  more  or 
less  homogenous,  and  of  well  defined  margin.  Since  the  central 
opacity  may  obscure  glands  on  the  left  side,  plates  should  be 
taken  in  an  oblique  position,  the  rays  passing  from  behind  on 
one  side  to  in  front  on  the  other.  In  this  way  the  spinal  column, 
heart,  and  great  vessels  will  be  seen  separated  by  clear  space, 
unless  diseased  glands  are  present  hi  the  mediastinum. 

X-Ray  Diagnosis  not  Easy. — Diagnosis  of  disease  of  the  bron- 
chial glands  by  means  of  the  X-ray  is  not  an  easy  matter.  The 
skiagram  should  be  taken  and  the  plates  interpreted  by  a  special- 
ist, skilled  hi  this  line  of  work. 

Even  when  glands  which  cast  shadows  are  found,  one  is  not 
assured  by  the  X-ray  plate  that  he  is  dealing  with  an  active 
tuberculosis.  The  X-ray  is  thus  of  value  only  when  the  clinical 
findings  are  used  in  conjunction  with  it.  Upon  our  clinical 
findings  must  we  base  our  opinion,  that  the  glandular  enlarge- 
ment is  due  to  tuberculosis  by  excluding  other  conditions,  which 
might  cause  an  enlargement  of  these  glands.  Likewise  we  must 
depend  upon  clinical  observation  in  basing  our  opinions  as  to 
the  activity  of  the  lesions.  Calcified  glands,  which  show  most 
distinctly  on  the  X-ray  plates,  tend  to  indicate  a  lesion  which  is 


DIAGNOSIS  115 

undergoing  healing.  DUNHAM  and  WOLMAN  l  state  that  the 
presence  of  calcined  glands,  other  conditions  being  favorable, 
may  be  taken  as  a  good  prognostic  sign. 

TUBERCULOSIS  OF  THE  CERVICAL  GLANDS 

As  a  rule  tuberculosis  of  the  cervical  glands  presents  little 
difficulty  in  diagnosis.  The  suspicion  of  tuberculosis  should  be 
entertained  in  every  case  of  chronic  enlargement  of  these  glands. 
The  location  of  the  swellings,  their  slow  course  without  apparent 
cause  in  most  instances,  and  the  presence  of  large  masses  of 
glands  bound  together  by  adhesions,  all  point  to  tuberculosis. 
The  chronicity  and  comparative  absence  of  symptoms  is  of  much 
importance  in  diagnosis. 

The  tendency  to  caseation  and  suppuration  is  characteristic, 
and  when  the  glands  have  ruptured  and  indolent  discharging 
sinuses  and  puckered  scars  exist,  the  diagnosis  is  relatively  easy. 
The  formation  of  fistulae,  the  thin  fluid  secretion  containing 
caseous  fragments,  and  the  usually  long  standing,  indicate  the 
tuberculous  nature  of  the  lesions,  while  thick  yellow  pus,  an 
acute  course,  marked  inflammatory  symptoms,  and  early  scarring, 
indicate  a  different  origin.  While  the  onset  of  the  enlargement 
is  at  times  acute,  the  persistence  of  the  increased  bulk  of  the 
glands,  after  the  subsidence  of  the  acute  manifestations,  should 
lead  one  to  think  of  tuberculosis. 

Must  be  Differentiated  from  the  Following  Diseases. — Tuber- 
culosis of  the  cervical  glands  must  be  differentiated  from  a  num- 
ber of  conditions,  causing  chronic  glandular  enlargement  in 
this  region. 

Syphilis  is  a  common  cause  of  enlargement  of  these  glands. 
In  the  early  stages  of  syphilis  the  glands  of  the  groin,  axilla  and 
epitrochlear  regions  are  affected.  Later  the  glandular  involve- 
ment is  more  extensive.  In  the  neck  the  glands  of  the  posterior 
cervical  region  are  more  distinctly  indurated,  while  in  tuber- 
culosis the  anterior  chains  are  most  often  affected.  Suppuration 
of  these  glands  is  rare.  There  may  be  a  history  of  syphilitic  in- 
fection, or  concomitant  signs  of  syphilis  may  be  present.  A  pos- 


u6     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

itive  Wasserman  blood  test  may  be  obtained.  The  glandular 
enlargement  subsides  under  anti-syphilitic  treatment. 

In  Lymphatic  Leukemia  the  cervical  glands  may  be  enlarged. 
Anaemia  develops  more  rapidly  than  in  the  tuberculous  infection. 
The  blood  examination  clears  up  the  diagnosis,  the  large  number 
of  white  cells  and  the  presence  of  myelocytes  being  pathogno- 
monic. 

Pseudoleukemia  or  Hodgkin's  disease,  may  require  differen- 
tiation. In  the  early  stages  the  cervical  glands  alone  may  be 
enlarged.  Sooner  or  later  other  groups  are  involved.  The 
disease  is  rare  in  children,  being  most  commonly  observed  in 
adult  males.  The  posterior  cervical  and  the  supra-clavicular 
groups  are  most  often  affected.  Less  often  the  submaxillary  or 
anterior  cervical.  The  glands  are  more  freely  movable  and  less 
sensitive  than  tuberculous  glands.  Their  consistency  is  uniform, 
and  they  do  not  caseate  or  suppurate.  In  doubtful  cases  the 
diagnosis  can  be  established  by  excision  of  a  node  and  microscop- 
ical examination. 

With  tuberculous  nodes  the  X-ray  examination  may  show 
spots  of  calcium  salt  deposits.  Although  not  commonly  found 
it  is  very  characteristic  of  tuberculosis  when  noted. 

Cysts. — Large  solitary  glands  may  resemble  cysts.  In  favor 
of  cysts  is  their  location  in  the  neck  in  a  position  typical  of  these 
structures.  The  presence  of  smaller  nodes  immediately  sur- 
rounding these,  speaks  for  tuberculosis.  In  doubtful  cases  the 
test  puncture,  or  an  examination  after  excision,  settles  the 
diagnosis. 

Malignancy. — In  old  age  solitary  glands  must  be  distinguished 
from  malignancy.  They  should  lead  to  a  search  for  a  primary 
malignant  lesion,  and  in  doubtful  cases  the  diagnosis  should  be 
made  positive  by  excision  and  microscopical  examination. 

Sarcoma  of  the  lymphatic  glands  is  to  be  distinguished  by  the 
more  rapid  enlargement  of  the  nodes,  and  the  early  involvement 
of  the  adjacent  tissues. 

Actinomycosis  rarely  causes  difficulty  in  the  diagnosis.  The 
sulphur  granules  made  up  of  the  ray  fungi,  found  in  the  pus, 
are  diagnostic. 


DIAGNOSIS  117 

TUBERCULOSIS  OF  THE  MESENTERIC  GLANDS 

Tuberculosis  of  the  mesenteric  glands  frequently  runs  its 
course  without  pressure  symptoms  or  functional  disturbances, 
its  only  indication  being  general  symptoms  such  as  increased 
temperature,  pallor  and  loss  of  weight.  Abdominal  pain  and 
watery  offensive  stools,  due  to  the  associated  intestinal  condition, 
are  suggestive. 

Tuberculosis  of  these  glands  can  be  diagnosed  with  certainty, 
when  the  glands  are  palpable.  Considerable  enlargement  is 
necessary,  before  they  can  be  felt.  Palpation  is  often  hindered 
by  flatulent  distension  or  faecal  accumulations.  Deep  palpation 
in  the  region  of  the  umbilicus  may  detect  firm  or  movable  masses 
on  either  side  of  the  spinal  column.  One  must  assure  himself 
that  the  bodies  felt  are  not  masses  attached  to  the  omentum,  or 
lumps  of  hardened  fasces.  The  former  are  more  superficial  and 
consequently  more  easily  felt  than  glands  and  are  more  freely 
movable.  Faecal  masses  are  elongated  and  of  moderate  size 
with  their  long  axes  in  the  direction  of  the  bowel  and  they  are 
situated  at  some  place  along  the  colon.  They  are  not  deeply 
placed  and  are  more  easily  reached  than  glands;  they  can  be 
indented  by  firm  pressure.  In  case  of  doubt,  faecal  masses  are 
easily  removed  by  a  copious  enema  or  by  a  cathartic,  while 
masses  due  to  any  other  cause  are  made  more  evident.  Enlarged 
glands  can  occasionally  be  felt  by  rectal  palpation. 

Percussion  will  often  manifest  checker-board  dulness,  this 
may  be  difficult  to  determine  in  inactive  cases  of  tuberculous 
enlargement  of  the  mesenteric  glands,  but  is  more  easily  shown 
when  there  is  activity  in  these  glands,  with  its  accompanying 
inflammatory  exudative  changes,  and  is  a  valuable  diagnostic 
sign.  It  may  be  an  aid  in  determining  activity.  This  sign  may 
also  be  present  in  tuberculosis  of  the  intestines,  mesentery  or 
parietal  peritoneum. 

TUBERCULOSIS  OF  OTHER  LYMPHATIC  GLANDS 

The  Axillary  Glands. — The  diagnosis  of  tuberculosis  of  the 
axillary  glands  is  rarely  difficult.  The  chronicity  and  persistence 


n8     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

of  the  infection  and  the  association  with  tuberculous  cervical 
glands,  tuberculosis  of  the  mammary  gland,  or  with  a  tuber- 
culous affection  of  the  hand,  arm  or  forearm,  indicates  the  nature 
of  the  lesions. 

The  Cubital  Glands. — Tuberculous  cubital  glands  likewise  can 
be  diagnosed  with  ease  when  there  is  a  tuberculous  lesion  in  the 
area  tributary  to  these  glands,  which  is  the  evident  source  of  in- 
fection. Enlargement  of  the  epitrochlear  glands  is  common  in 
syphilis,  and  in  the  absence  of  a  local  infection  and  a  recent 
acute  general  infection,  is  considered  by  many  as  pathognomonic 
of  lues.  Glandular  enlargement  due  to  lues  will  respond  to 
antisyphilitic  treatment. 

The  Inguinal  Glands. — Tuberculosis  of  the  inguinal  glands  is 
often  mistaken  for  a  complication  of  some  venereal  disease,  at 
least  until  its  stubbornness,  chronicity  and  resistance  to  treat- 
ment arouse  a  suspicion  of  tuberculosis.  Since  venereal  diseases, 
and  especially  syphilis,  are  the  most  common  cause  of  inguinal 
adenopathy,  they  should  be  thought  of  at  once  and  eliminated. 
Careful  examination  of  the  patient  may  reveal  a  tuberculous 
lesion  of  the  genitalia,  or  of  the  feet,  which  is  the  source  of  the 
glandular  infection.  In  cases  where  it  is  very  desirous  to  elim- 
inate Hodgkin's  disease,  or  a  possible  malignancy,  a  gland  may 
be  excised  for  microscopic  examination  or  animal  inoculation. 
A  large  tuberculous  gland  in  the  inguinal  or  femoral  region  may 
simulate  the  appearance  of  a  hernia. 

The  Popliteal  Glands. — What  has  been  said  in  regard  to  the 
diagnosis  of  other  glands  will  apply  to  the  popliteal  nodes.  The 
chronicity  of  the  infection  and  the  presence  of  a  lesion,  which 
serves  as  the  source  of  the  infection,  are  the  most  important 
points.  Although  tuberculosis  of  the  popliteal  glands  is  rare,  as 
statistics  show,  it  should  not  be  forgotten. 

SPECIFIC  DIAGNOSTIC  METHODS 

Tuberculin  Diagnosis.— "Tuberculin  is  the  most  exact  and 
finest  reagent  for  proving  the  existence  of  a  tubercular  deposit, 
in  the  living  organism."  2  The  result  of  tuberculin  reactions 


DIAGNOSIS  119 

have  not  fulfilled  the  greatest  hope  that  was  built  upon  them, 
following  the  announcement  of  their  application  in  the  specific 
diagnosis  of  tuberculous  lesions.  But  they  do  have  a  definite 
value  and  have  thrown  much  light  upon  important  questions 
in  tuberculosis,  especially  as  an  aid  in  making  an  early  diagnosis 
of  tuberculosis,  also  in  determining  the  time  of  the  infection, 
and  the  great  prevalence  of  latent  infections;  they,  therefore, 
merit  careful  consideration.  In  using  tuberculin  for  diagnostic 
purposes  we  may  make  use  of  the  cutaneous  tests,  including  that 
described  by  v.  Pirquet,  the  intracutaneous  and  percutaneous 
reactions,  the  conjunctival  test  of  Wolf-Eisner  or  the  subcuta- 
neous test. 

Different  Tests. — In  the  cutaneous  tests  the  tuberculin  is  in- 
troduced into  the  superficial  lymph  spaces  of  the  skin,  and  does 
not  gain  access  to  the  blood-stream.  The  interaction,  occurring 
between  the  immune  substances  and  the  tuberculin,  liberates 
the  toxins  from  the  tubercle  bacillus  protein  contained  in  it  and 
this  occasions  the  inflammatory  reaction  at  the  site  of  application. 
In  the  subcutaneous  test  the  tuberculin  gains  access  to  the  blood- 
stream, and  in  a  sensitized  individual  gives  rise  to  a  general 
reaction  with  a  rise  of  temperature  of  a  variable  extent,  constitu- 
tional symptoms  of  toxaemia,  and  a  focal  reaction  at  the  site  of 
disease  which  may  cause  an  exaggeration  of  the  signs  and  symp- 
toms recognizable  clinically.  In  addition,  there  is  a  local  in- 
flammatory reaction  at  the  site  of  application  of  the  tuberculin 
to  the  subcutaneous  tissues.  For  a  discussion  of  the  theories  of 
the  tuberculin  reactions  see  chapter  on  Tuberculin  treatment. 

CUTANEOUS  TUBERCULIN  TESTS 

v.  Pirquet's  Test. — The  cutaneous  test  of  v.  Pirquet  is  one 
of  the  most  extensively  used  and  is  a  valuable  tuberculin  test, 
being  easily  performed  and  harmless. 

The  site  usually  chosen  is  the  inner  side  of  the  forearm  because 
of  its  delicate  and  less  hairy  surface  and  the  ease  of  observation. 
In  children  the  outer  aspect  of  the  arm  may  also  be  employed. 
The  skin  is  first  cleansed  with  alcohol  or  ether  and  quickly  dried 


120     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

by  evaporation.  Two  drops  of  Koch's  old  tuberculin  are  then 
placed  about  four  inches  apart.  The  skin  is  stretched  taut  and 
scarified  by  means  of  a  chisel-shaped  instrument  made  for  the 
purpose,  a  needle,  or  the  point  of  a  scalpel,  first  at  a  point  mid- 
way between  the  drops  as  a  means  of  control,  and  then  in  the 
drops  themselves.  The  scarification  should  be  but  deep  enough 
to  open  the  superficial  lymphatics  of  the  skin,  any  considerable 
oozing  of  blood  to  be  avoided  as  in  vaccination.  The  scarifier 
should  be  heated  before  use  to  remove  any  tuberculin  that  may 
be  present  from  a  previous  test  as  this  would  cause  a  reaction  at 
the  site  of  control.  The  tuberculin  is  allowed  to  dry  for  several 
minutes  and  the  excess  is  then  removed  with  a  bit  of  cotton. 

Positive  Reaction. — The  slight  inflammatory  reaction  in- 
cident to  the  trauma  soon  abates.  The  true  reaction  usually 
makes  its  appearance  within  twelve  to  twenty  hours  after  the 
application  of  the  tuberculin.  On  rare  occasions  it  appears 
within  four  to  six  hours.  The  extent  of  the  reaction  varies.  In 
mild  reactions  there  is  slight  redness  and  infiltration,  while  in 
more  severe  types  the  redness  covers  a  more  extensive  area,  and 
the  infiltration  results  in  a  well-marked  papule  from  three  to 
twenty  mm.  in  diameter.  The  reaction  reaches  its  height  in 
twenty-four  to  thirty-six  hours,  and  the  inflammation  then  sub- 
sides. The  patient  experiences  only  slight  pain  or  itching;  gen- 
eral reaction  and  fever,  as  well  as  focal  reactions  are  almost  in- 
variably absent,  although  they  have  been  observed. 

In  rare  instances  the  latent  period  exceeds  twenty-four  hours, 
and  reaction  phenomena  are  sometimes  delayed  four  or  five  days. 
Such  late  reactions  occur  in  clinically  unsuspected  cases  and  only 
exceptionally  in  manifest  tuberculosis.  In  a  negative  reaction 
the  points  of  inoculation  appear  like  the  control.  It  requires 
some  experience  to  distinguish  minimal  reactions  from  traumatic 
or  negative  ones.  v.  Pirquet  recommends  that  the  beginner 
regard  as  doubtful  all  reactions  under  five  mm.  in  diameter  and 
to  repeat  the  test.  Now  and  then  the  first  test  is  negative,  and 
an  intense  reaction  occurs  when  it  is  repeated. 

Reaction  Due  to  Hypersensitiveness. — The  test  depends  on 
the  hypersensitiveness  of  the  skin  of  the  tuberculous  person  to 


DIAGNOSIS  121 

the  small  amount  of  tuberculin  taken  up  by  the  lymphatics. 
The  test  may  be  considered  as  specific  in  demonstrating  hyper- 
sensitiveness  due  to  the  presence  of  a  tuberculous  focus.  It  does 
not,  however,  offer  an  accurate  indication  as  to  the  state  of 
activity  of  this  focus,  unless  other  factors  are  considered.  His- 
tological  examination  of  excised  papules  shows  nodular  masses 
of  epitheloid  cells,  partly  surrounded  by  a  zone  of  round  cells, 
the  typical  giant  cells  of  Langhans  and  distended  capillaries, 
the  picture  of  typical  tubercles  without  caseation  changes  such 
as  are  caused  by  toxins  of  the  tubercle  bacillus.3 

The  test  has  been  applied  in  a  very  large  number  of  cases. 
It  is  important  in  that  it  has  permitted  the  recognition  of  latent 
foci  and  given  information  as  to  the  great  frequency  of  tuber- 
culous infections  and  the  time  of  its  occurrence. 

Frequency  of  Infection. — The  following  table  given  by  VEEDER 
and  JOHNSON  4  shows  the  frequency  of  infection  according  to 
age  as  determined  by  the  v.  Pirquet  reaction: 

St.  Louis  Vienna 

Age  Veeder  and  Johnson  v.  Pirquet  Hamburger 

Under  i  year  i-5%  o%  o% 

5-5%  o%  9% 


1-2 

2-4 
4-7 


19%  13%  26% 

25%  30%  54% 


30%  38%  75% 

36%  ?o%  94% 

In  Adults  of  Little  Value.  —  A  positive  v.  Pirquet  reaction  gives 
us  no  information  as  to  the  site  of  the  tuberculous  disease.  Those 
who  are  clinically  tuberculous  and  the  non-clinically  or  anatom- 
ically tuberculous  give  a  response.  These  facts  limit  to  a  very 
great  extent  the  diagnostic  value  of  the  reaction  in  adults;  a 
positive  reaction  affords  us  no  practical  conclusion  as  to  treat- 
ment. v.  Pirquet  did  not  regard  this  method  as  appropriate 
for  use  in  adults.  In  them  it  must  be  subservient  to  clinical 
manifestations  of  disease.  When  distinctly  positive  and  accom- 
panied by  considerable  infiltration  and  erythema  about  the 
site  of  application  of  the  tuberculin,  a  thorough  examination 
and  careful  observation  of  the  patient  is  imperative. 


122 


TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 


Great  Value  in  Children.— In  young  children  the  test  is  of 
greater  importance  since  it  enables  the  time  of  infection  to  be 
determined.  The  younger  the  child  the  greater  its  value.  In 
sucklings  a  positive  reaction  proves  the  presence  of  active 
tuberculosis,  and  a  negative  reaction  the  absence  of  infection. 
In  older  children,  as  in  adults,  many  who  react  are  clinically 
healthy,  possessing  only  small  inactive  foci. 

We  may  conclude — 

1.  That  the  cutaneous  test  is  specific. 

2.  That  the  cutaneous  reaction  is  almost  invariably  positive 
when  tuberculosis  is  present  except  under  certain  well  defined 
conditions. 

3.  That  the  test  may  be  negative  in  case  of  acute  rmliary 
tuberculosis,  tuberculous  meningitis,  the  terminal  stages  of  pul- 
monary tuberculosis,  and  in  acute  infectious  diseases  as  described 
below. 

All  reactions  occurring  in  young  children  should  be  regarded 
as  suspicious.  A  negative  test  in  a  child  under  ten  years,  care- 
fully performed,  excluding  advanced  tuberculosis  or  a  recent  at- 
tack of  measles  or  other  acute  disease,  is  as  good  evidence  as 
can  be  obtained  that  the  condition  is  non-tuberculous.  On  the 
other  hand,  a  positive  test  in  a  child  over  six  years  must  not  be 
estimated  too  highly  as  evidence  of  clinical  tuberculosis. 

Degree  of  Reaction  as  a  Guide. — The  degree  of  reaction  is 
no  guide  to  the  extent  of  a  tuberculous  process  but  may  be  in- 
dicative of  the  degree  of  resistance,  and  the  quantity  of  immune 
bodies  possessed  by  the  individual  and  with  certain  limitations 
may  give  information  as  to  the  state  of  activity  of  the  lesions. 
Thus  in  active  disease  the  body  cells  react  and  produce  larger 
quantities  of  free  circulating  antibodies.  Such  cases  usually 
reach  a  maximum  cutaneous  reaction  within  twenty-four  hours. 
In  disease  which  is  healing  and  approaching  quiescence  it  may 
be  assumed  that  there  are  fewer  circulating  antibodies,  and  the 
maximum  is  reached  subsequent  to  twenty-four  hours.  In 
healed  cases  the  reaction  occurs  late  and  is  slight.  In  attempting 
to  compare  the  v.  Pirquet  reaction  with  clinical  manifestations 
it  is  to  be  remembered  that,  on  the  basis  of  the  latter,  different 


DIAGNOSIS  123 

observers  will  draw  different  conclusions  as  to  the  state  of  activ- 
ity of  the  disease. 

Pottenger's  Views. — POTTENGER  5  has  made  a  study  of  the 
test  in  regard  to  its  availability  as  an  index  of  the  state  of  ac- 
tivity of  a  tuberculous  focus.  In  drawing  his  conclusions  he 
considers  points  in  the  history  indicative  of  the  activity  of  the 
disease,  the  physical  signs,  the  condition  of  the  muscle,  noting 
spasm  or  degeneration,  and  any  diminutions  in  motion  of  the 
diaphragm  as  shown  in  a  limitation  of  motion  of  the  side  of  the 
chest.  Positive  active  lesions  showed  uniformity  in  reaction.  I 
quote  the  following  from  him — "It  (the  reaction)  usually  came 
on  early,  manifesting  itself  even  as  early  as  six  hours  in  some 
cases.  In  most  cases,  however,  where  it  was  given  in  the  after- 
noon the  reaction  would  be  found  in  the  morning  on  the  patient's 
awakening.  This  would  increase  in  severity  during  the  next 
day  reaching  its  maximum  before  or  about  the  end  of  the  twenty- 
four  hours.  It  would  remain  at  its  height  for  a  short  time  and 
then  gradually  disappear.  Aside  from  the  reaction  coming  on 
soon  in  these  early  active  cases,  it  was  usually  well  marked. 
In  those  patients  where  I  had  given  an  opinion  that  there  was 
a  latent  lesion,  I  usually  found  that,  while  the  reaction  might  be 
in  evidence  the  following  morning  and  keep  increasing  during 
the  first  twenty-four  hours,  it  would  probably  not  reach  its 
maximum  until  the  second  day  and  in  some  instances  even  the 
third.  The  reaction  in  these  cases  was  also  quite  marked  but 
the  principal  thing  I  noticed  was  that  it  did  not  come  on  so 
early.  In  the  border-line  cases  we  had  variations  between 
these  two  reactions.  A  reaction  might  come  on  early  but  keep 
increasing  after  the  first  twenty-four  hours.  It  was,  as  a  rule, 
not  a  marked  reaction  when  a  case  was  practically  healed. 
When  we  could  find  no  evidence  of  anything  but  an  old  lesion 
with  no  clinical  symptoms  and  nothing  to  indicate  activity,  as  a 
rule  we  had  a  very  slight  reaction  on  the  day  following  the  in- 
oculation, which  rarely  increased  to  any  extent."  From  a  study 
of  forty-four  cases  of  suspected  early  pulmonary  tuberculosis, 
the  clinical  history,  physical  examination,  condition  of  the 
muscles  and  the  v.  Pirquet  taking  the  twenty-four  hour  limit 


I24     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

as  indicative  of  activity,  they  agreed  in  76.2%  of  cases  giving  a 
percentage  of  difference  of  23.8%.  The  clinical  history,  physical 
examination  and  the  v.  Pirquet  based  on  twenty-four  hour  limit 
agree  in  78.2%  giving  a  difference  of  21.4.%." 

POTTENGER  further  states:  "It  is  possible  that  the  twenty-four 
hour  is  not  the  correct  one  to  differentiate  between  active  and 
quiescent  lesions,  but  >et,  as  my  cases  will  show,  it  was  correct 
in  the  majority  of  instances.  It  makes  me  at  least  feel  that  a  v. 
Pirquet  which  comes  on,  reaching  its  maximum  within  twenty- 
four  hours  from  the  time  the  inoculation  was  given,  is  indicative 
of  an  active  tuberculous  process.  If  these  results  can  be  con- 
firmed by  others  the  v.  Pirquet  test  may  yet  be  saved  to  the  pro- 
fession as  a  means  of  differentiation  between  active  and  quies- 
cent lesions." 

From  a  personal  study  of  ten  cases  of  clinically  healed  tuber- 
culosis that  were  active  when  first  observed,  but  had  recovered 
under  tuberculin  treatment,  five  years  having  passed  since  any 
tuberculin  was  given  them,  the  following  findings  were  observed 
which  are  of  marked  interest.  These  cases  were  all  subjected 
to  the  v.  Pirquet  test.  At  the  end  of  twenty-four  hours  one  case 
gave  a  slight  reaction,  which  increased,  reaching  its  height  at 
thirty-six  hours  and  was  slow  in  subsiding.  At  the  end  of  thirty- 
six  hours  a  slight  reaction  was  present  in  five  more  of  the  cases, 
and  at  the  end  of  forty-eight  hours  there  was  only  a  faint  trace 
of  these  reactions  present.  At  the  end  of  forty-eight  hours  the 
remaining  four  cases  gave  a  very  faint  reaction,  the  evidence  of 
which  lasted  from  four  to  twelve  hours. 

The  clinical  history  and  physical  findings  at  the  time  of 
this  investigation  indicated  that  there  were  no  active  tuberculous 
foci.  In  the  one  case  that  gave  a  reaction  at  the  end  of  twenty- 
four  hours  an  exhaustive  study  was  made,  but  there  was  nothing 
found  to  indicate  activity.  This  case  was  observed  for  one  year 
and  there  developed  no  evidence  of  any  further  tuberculous  in- 
volvement. 

The  v.  Pirquet  tuberculin  test  gave  100%  of  reactions  in  these 
ten  cases  of  clinically  healed  tuberculosis;  10%  reacted  at  the 
end  of  twenty-four  hours,  50%  reacted  at  the  end  of  thirty-six 


DIAGNOSIS  125 

hours,  and  at  the  end  of  forty-eight  hours  100%  had  reacted; 
90%  of  the  reactions  occurred  after  the  "twenty-four  hour" 
time  limit.  The  results  observed  would  tend  to  confirm  the  value 
of  a  v.  Pirquet  test  as  an  aid  in  determining  the  activity  or  in- 
activity of  a  tuberculous  lesion. 

As  a  result  of  my  investigations,  I  believe  that  the  positive 
v.  Pirquet  test  must  be  regarded  as  of  little  value  in  children 
over  three  years  of  age,  or  in  adults,  unless  the  time  limit  reaction 
is  taken  into  consideration. 

A  negative  v.  Pirquet,  in  the  absence  of  manifest  tuberculosis 
in  either  children  or  adults,  is,  I  believe,  definite  evidence  of  the 
freedom  from  either  a  latent  or  an  active  tuberculosis. 

TICE  6  concludes  from  his  experiments  that  a  negative  test 
in  the  adult,  all  circumstances  considered,  is  of  more  value  than 
a  positive  one. 

PERCUTANEOUS  TEST 

Ointment  Test. — The  application  of  tuberculin  to  the  skin 
in  ointment  form,  has  been  employed  for  diagnostic  purposes  by 
MORO  and  DOGANOFF  in  their  percutaneous  test.  They  make 
use  of  an  unguentum  consisting  of  equal  parts  of  old  tuberculin 
and  anhydrous  lanolin.  The  preparation  darkens  with  age  but 
retains  its  potency  for  some  time.  For  the  test,  a  portion  of  the 
ointment  as  large  as  a  pea  is  thoroughly  rubbed  into  the  skin 
for  one  minute  over  an  area  of  about  five  centimeters  in  diameter. 
The  upper  abdomen,  or  the  region  about  the  nipple  offers  the 
most  favorable  site  for  the  test. 

Positive  Manifestations. — In  a  positive  test  there  occurs  at 
the  site  of  inunction  within  twelve  to  twenty-four  hours  an 
efflorescence  of  papules.  They  are  red  in  color  and  accompanied 
by  some  erythema  of  the  surrounding  skin.  They  become  well 
marked  in  twenty-four  hours  and  reach  their  height  in  forty- 
eight  hours  in  a  typical  response.  Their  appearance  may  be 
delayed  in  some  instances  until  the  third  or  fourth  day.  The 
intensity  of  the  reaction  varies  with  the  individual  cases.  There 
may  be  only  a  few  papules,  or  they  may  be  numerous,  closely 
set  and  accompanied  by  inflammation  of  the  surrounding  skin. 


126 

In  most  severe  reactions  they  may  go  on  to  vesiculation.  The 
reactions  are  particularly  severe  in  so-called  scrofulous  individ- 
uals, in  whom  there  may  be  papular  eruptions  at  various  places 
in  the  skin,  in  addition  to  the  area  which  has  been  anointed  with 
the  tuberculin  ointment. 

I  have  observed  that  when  the  infection  involves  structures 
rich  in  blood  supply,  such  as  the  skin,  the  reaction  to  tuberculin 
is  severe,  but  if  there  is  a  limited  blood  supply  as  in  the  bones, 
the  response  is  mild.  This  is  undoubtedly  due  to  the  fact  that 
in  the  one  instance  there  is  an  opportunity  for  extensive  antibody 
contact,  and  in  the  other  it  is  limited. 

Test  Uncertain. — The  test  is  more  or  less  uncertain.  There  is 
a  difference  in  the  powers  of  absorption  of  various  skins.  The 
length  of  time  and  the  vigor  employed  in  applying  the  ointment 
will  result  in  a  variation  in  degree  of  absorption,  consequently 
in  the  test  there  is  considerable  difficulty  in  judging  the  degree 
of  reaction.  It  is  usually  judged  by  the  number  of  papules  which 
appear,  and  by  the  extent  of  the  inflammatory  disturbance.  But 
since  variation  may  be  the  result  of  other  factors,  the  value  of 
the  test  as  an  index  of  the  reactivity  of  the  individual  to  tuber- 
culin is  thus  limited.  The  test  is  of  much  less  value  than  either 
the  cutaneous  or  subcutaneous. 

The  individual  making  the  test  will  do  well  to  protect  with  a 
rubber  cot  the  finger  which  he  uses  to  apply  the  ointment. 
Ordinarily  there  is  no  danger,  but  if  the  rubbing  with  the  unpro- 
tected finger  is  continued  long  enough,  sufficient  tuberculin 
may  be  absorbed  to  cause  a  local  reaction.  The  test  may  be 
employed  in  the  case  of  children  in  which  there  is  vigorous  ob- 
jection to  the  hypodermic  injection,  or  to  the  scarification  for 
the  v.  Pirquet.  But  practically  these  objections  to  the  other 
more  reliable  tests  are  negligible,  and  consequently  I  do  not  em- 
ploy the  percutaneous  test.  If  made  use  of,  a  reaction  occurring 
as  described  may  be  taken  as  evidence  of  "immune  bodies"  to 
tuberculosis,  the  test  being  specific.  Negative  reactions  are  in- 
terpreted the  same  as  for  the  other  tests.  Like  the  v.  Pirquet 
the  greatest  practical  value  is  in  its  use  in  children.  There  are 
no  contraindications  to  its  use  except  in  case  of  so-called  "scrof- 


DIAGNOSIS  127 

ulous"  children,  in  whom  the  reaction  may  be  severe  and  ex- 
tensive. 

Intracutaneous  Test.  Method  Employed. — MANTOUX  and 
Roux  have  described  and  employed  the  intradermic  injection 
of  dilute  solutions  of  tuberculin  for  diagnostic  purposes.  The 
technique  of  the  performance  of  this  test  is  as  follows : — 

The  skin  of  the  forearm  is  chosen  as  the  site  of  injection  and 
is  cleansed  with  iodine  or  ether.  A  sterile  glass  syringe  equipped 
with  a  very  fine  needle  is  employed  for  the  injection.  The  skin 
is  stretched  and  the  needle  inserted  nearly  parallel  with  the  sur- 
face, with  the  aperture  of  the  needle  directed  upward  until  the 
point  is  within,  but  not  through,  the  skin.  One  drop  of  a  1 15000 
dilution  of  old  tubercuh'n  is  injected.  A  white  elevation  of  the 
skin  is  evidence  that  the  injection  is  intradermic.  A  control 
injection  may  be  made  using  the  diluent. 

Local  Manifestations. — When  the  reaction  is  positive  a  slight 
infiltration,  perceptible  to  the  sight  or  touch,  is  noted  in  five  or 
six  hours.  At  the  end  of  twenty-four  hours  the  reaction  is  usually 
well  marked.  At  the  sight  of  injection  there  is  a  red  papule  which 
is  surrounded  by  a  zone  of  erythema.  The  size  of  the  papule 
varies  little,  the  violence  of  the  reaction  being  determined  by 
the  size  of  the  halo.  The  reaction  is  at  its  height  at  the  end  of 
forty-eight  hours,  and  during  the  second  or  third  day  begins 
to  recede.  The  peripheral  halo  first  disappears;  the  papule 
becomes  violet  in  color,  then  brownish,  and  disappears  in  two 
or  three  weeks.  If  no  reaction  occurs  with  the  dose  mentioned, 
it  may  be  increased  and  the  test  repeated. 

No  General  Symptoms. — The  injection  may  occasion  itching, 
discomfort  and  sometimes  slight  pain.  There  are  rarely  ever  any 
general  symptoms  unless  the  tuberculin  is  injected  in  part  be- 
neath the  skin,  when  a  febrile  reaction  may  occur.  When  the 
test  is  negative  there  is  slight  induration  and  brownish  discolora- 
tion which  disappears  in  two  or  three  days,  at  which  time  a 
positive  reaction  would  be  at  its  height. 

A  Delicate  Test. — This  reaction  is  probably  the  most  delicate 
of  the  cutaneous  tests.  It  is  more  sensitive  than  the  v.  Pirquet, 
and  has  the  advantage  that  the  amount  of  tuberculin  introduced 


128     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

can  be  measured.  It  has  the  disadvantages  of  being  more 
difficult  to  perform  than  the  v.  Pirquet  and  causes  more  dis- 
comfort. In  adults  its  value  is  limited  as  in  the  other  tests.  By 
using  various  dilutions  of  tuberculin  different  degrees  of  reactivity 
may  be  noted,  and  as  a  means  of  estimating  the  degree  of  hyper- 
sensitiveness  it  has  no  equal.  It  is  superior  to,  but  less  practical, 
than  the  v.  Pirquet  and  is  applicable  to  cases  where  the  sub- 
cutaneous method  is  contraindicated. 

Conjunctival  Test. — Instillations  of  solutions  of  tuberculin 
into  the  conjunctival  sac  have  been  used  for  diagnostic  purposes, 
and  were  first  described  by  Wolff-Eisner  and  Calmette  as  the 
conjunctival  and  ophthalmic  tests. 

Method  of  Employment. — The  lower  lid  is  gently  drawn 
down  and  one  drop  of  i%  solution  of  old  tuberculin  is  gently 
dropped  into  the  conjunctival  sac  from  a  pipette  or  ordinary 
medicine  dropper.  The  drop  should  be  allowed  to  fall  gently, 
and  the  pipette  held  near  so  that  the  eye  is  not  irritated,  and  the 
drop  should  be  immediately  expressed  by  the  closing  of  lids, 
or  washed  away  by  the  increased  lachrymation.  The  lid  should 
be  held  down  for  a  half  minute  to  permit  the  conjunctiva  to  be 
bathed  with  the  solution.  A  protective  dressing  may  be  used  to 
exclude  traumatic  irritation,  but  this  is  usually  not  necessary. 
Koch's  old  tuberculin  is  used,  the  diluent  being  sterile  normal 
saline. 

Evidence  of  Reaction. — A  positive  reaction  is  indicated  by 
reddening  of  the  conjunctiva,  which  appears  in  six  to  twenty- 
four  hours.  In  mild  reactions  the  inner  canthus  and  lachrymal 
caruncle  are  the  seat  of  most  marked  changes.  In  more  severe 
reactions  swelling  of  the  follicles  and  a  flow  of  tears  appear; 
the  ocular  conjunctiva  and  the  sclera  are  also  involved,  or  a 
fibrous  or  suppurative  secretion  is  seen  with  oedema  of  the  lid. 
Subjectively  the  reaction  resembles  an  ordinary  conjunctivitis, 
and  gives  a  sensation  of  a  foreign  body  or  a  feeling  of  heat, 
itching  and  pain.  The  inflammatory  reaction  reaches  its  max- 
imum in  twenty-four  to  thirty-six  hours  and  then  subsides  in 
mild  responses,  being  over  in  two  or  three  days  and  in  more 
severe  reactions  in  four  to  six  days. 


DIAGNOSIS  129 

In  case  the  reaction  proves  to  be  negative  and  it  is  desired  to 
repeat  the  test,  the  tuberculin  solution  may  be  used  in  the  same 
strength  or  increased  to  5%  concentration.  The  test  must  not 
be  repeated  in  the  same  eye  since  the  reaction  to  a  second  drop 
may  be  alarmingly  severe.  Wolff-Eisner  claimed  that  the  test 
could  be  employed  without  danger,  but  others  are  of  a  decidedly 
different  opinion. 

Contraindications. — There  are  numerous  contraindications 
to  the  use  of  this  diagnostic  reaction.  Existing  inflammation 
of  the  conjunctiva  or  uveal  tract  contraindicates  its  use.  CAL- 
METTE  and  WOLFF-EISNER,  however,  employed  it  in  the  presence 
of  mild  conjunctivitis.  History  of  previous  eye  disease  such  as 
phlyctenular  conjunctivitis  is  likewise  a  contraindication  be- 
cause of  the  danger  of  a  severe  reaction  which  may  prove  de- 
structive. It  should  not  be  employed  in  hyper-ergic  or  man- 
ifestly "scrofulous"  individuals  or  in  those  with  skin  lesions 
about  the  eye  suspected  of  being  tuberculous. 

Dangers. — Untoward  effects  may  be  noted  in  the  aged  for 
in  them  the  impaired  nutrition  of  the  cornea  may  lead  to  ulcera- 
tion.  Senility  and  arteriosclerosis,  therefore,  prohibit  its  applica- 
tion. Severe  and  serious  eye  changes  lasting  for  months  have 
been  observed  and  very  severe  keratitis,  corneal  opacity,  very 
acute  conjunctivitis  with  chemosis,  ulcers,  etc.,  have  occurred 
from  its  use,  even  with  the  application  of  fresh  tuberculin 
solutions  and  the  observance  of  proper  technique  in  every 
respect. 

Wolff-Eisner's  Views. — WOLFF-EISNER  believed  that  a  positive 
reaction  indicated  active  tuberculosis,  for  the  tuberculin  solution 
was  either  quickly  absorbed  or  washed  away.  Unless  a  large 
number  of  circulating  antibodies  were  present,  the  tuberculin 
would  be  carried  away  quickly  and  no  reaction  would  occur. 
But  this  belief,  that  only  the  clinically  tuberculous,  or  those  in 
danger  of  an  outbreak,  respond  to  the  conjunctival  test,  has  not 
been  sustained.  It  is  subject  to  the  same  limitations  as  the  other 
tests  and  has  been  observed  to  be  negative  in  cases  of  active 
tuberculosis,  and  positive  in  clinically  inactive  cases.  Since  the 
eye  is  such  a  delicate  and  all  important  organ,  and  the  test  not 


i3o      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

more  reliable  than  less  dangerous  ones,  it  is  folly  to  employ  it, 
and  it  is  little  used  at  the  present  time. 

Subcutaneous  Test.  Most  Valuable  Test. — The  subcuta- 
neous test  was  the  first  method  employed  in  the  use  of  tuberculin 
as  a  diagnostic  measure.  It  may  still  be  considered  as  the  last 
resort  and  most  searching  method  in  tuberculin  diagnosis,  as 
applied  to  doubtful  or  obscure  cases  of  tuberculosis.  I  prefer 
its  use  to  that  of  the  various  cutaneous  methods  previously 
described.  BANDELIER  and  ROEPKET  speak  of  it  as  the  most 
practically  serviceable,  and  most  fertile  in  results,  of  the  diagnos- 
tic methods.  In  younger  children  only  does  the  v.  Pirquet  test 
suffice,  and  the  subcutaneous  test  is  then  applicable  to  older 
children  and  adults. 

Accurate  Dosage. — In  employing  this  method  an  accurate 
dosage  of  tuberculin  is  obtained.  It  is  deposited  hi  the  subcuta- 
neous tissues  and  its  absorption  is  thus  assured.  In  addition  to 
the  local  inflammatory  reaction,  the  tuberculin  reaches  the  blood- 
stream and  is  distributed  throughout  the  body  resulting  in  a  gen- 
eral reaction.  This  affords  further  objective  evidence  of  the 
reactivity  of  the  body  to  tuberculin,  which  is  indicative  of  the 
presence  in  the  organism  of  the  immune  bodies  of  tuberculosis. 
The  irritation  of  the  focus  of  infection  constitutes  the  focal 
reaction,  which  is  absent  in  the  cutaneous  tests.  The  focal  re- 
action often  expresses  itself  clinically  by  the  appearance  of  symp- 
toms and  signs  of  disease,  also  the  exaggeration  of  existing  symp- 
toms, which  may  prove  of  great  value  in  locating  the  site  of  an 
obscure  tuberculous  focus. 

History  and  Examination  Prior  to  Test. — Before  applying 
the  subcutaneous  test  the  other  methods  of  diagnosis  should 
first  be  employed.  The  history  of  the  patient  should  be  taken 
in  detail,  noting  any  evidence  of  tuberculous  disease  and  its 
course  and  progress.  A  thorough  physical  examination  should 
be  made,  and  the  physical  signs  carefully  noted  and  recorded  for 
purposes  of  comparison  at  the  time  of  reaction,  and  to  facilitate 
the  recognition  of  a  focal  reaction.  The  patient  should  live  under 
the  same  conditions,  during  the  period  of  observation  preceding 
the  test  and  the  time  immediately  following,  in  order  that  extra- 


DIAGNOSIS  131 

neous  factors  may  be  eliminated  and  the  reaction,  if  one  occurs, 
be  properly  interpreted. 

Importance  of  Temperature  Range. — Since  the  increase  in 
temperature  is  an  important  part  of  the  reaction  to  the  sub- 
cutaneous test,  the  temperature  should  be  noted  for  at  least 
two  days  before  the  test  injection  is  given.  It  should  be  taken 
at  intervals  of  two  hours  and  recorded  on  a  chart.  In  a  hospital 
or  sanitarium  the  temperature  may  be  recorded  by  a  nurse  or 
attendant.  If  the  patient  is  in  the  home,  or  is  up  and  about, 
he  may  be  instructed  as  to  the  keeping  of  a  temperature  record. 
The  temperature  should  be  taken  accurately,  and  there  are  many 
sources  of  error.  The  thermometer  should  be  held  in  the  mouth 
long  enough  to  register.  To  insure  accuracy,  it  is  necessary  to 
hold  the  thermometer  for  two  or  three  times  the  interval  in  which 
it  is  supposed  to  register.  Thus  a  one-minute  thermometer 
should  be  retained  two  or  three  minutes.  Before  taking  his 
temperature,  the  patient  should  keep  his  mouth  closed  and 
avoid  talking  or  eating  and  drinking  as  these  affect  the  tem- 
perature of  the  mouth  for  some  time.  Rectal  temperature  is 
more  accurate.  In  the  female  the  menstrual  period  should  be 
avoided,  because  of  the  frequent  occurrence  of  menstrual  and 
premenstrual  fever,  and  also  out  of  consideration  for  the  patient's 
general  health  at  such  time.  If  the  patient  is  to  be  in  bed  after 
the  test  is  given  he  should  likewise  be  in  bed  during  the  days 
preceding.  This  is  not  essential,  however,  and  the  test  may  be 
applied  to  patients  who  are  about. 

Technique  of  Test. — Prior  to  making  the  subcutaneous  test, 
the  temperature  must  be  taken  at  regular  intervals  for  at  least 
two  days  to  determine  the  temperature  range,  as  well  as  the 
normal  for  the  individual.  This  temperature  range  may  be  as 
much  as  ij^  degrees  even  with  the  high  temperature  being  at 
normal  or  possibly  only  99  degrees.  A  period  of  subnormal 
temperature,  I  have  observed,  often  precedes  the  febrile  period 
in  tuberculosis  and  is  a  most  important  symptom  of  tuberculosis. 
The  average  temperature  for  the  two  preceding  days  may  be 
considered  as  the  temperature  for  the  individual,  and  must  be 


i32      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

the  base  from  which  the  reaction  temperature  is  figured,  whether 
it  be  afebrile  or  febrile. 

Method  Employed.— The  administration  of  tuberculin  in  the 
subcutaneous  test  does  not  differ  from  the  administration  of 
any  remedy  by  the  hypodermic  method.  Aseptic  technique, 
proper  dilution  and  dose  of  tuberculin  are  the  essentials  to  be 
observed.  An  all-glass  syringe  is  preferable,  since  it  can  be  easily 
sterilized  by  boiling.  Before  injection  the  skin  at  the  chosen 
site  should  be  cleansed  by  iodine  or  ether  and  allowed  to  dry 
by  evaporation.  The  choice  of  the  site  of  injection  is  a  matter 
of  little  consequence.  The  forearm,  arm,  lumbar,  abdominal 
and  interscapular  regions  have  all  been  employed.  Personally, 
I  make  use  of  the  outer  aspect  of  the  arm,  this  being  a  convenient 
site  for  observance,  and  for  injecting  the  tuberculin  into  the  sub- 
cutaneous tissues. 

For  the  subcutaneous  test  any  of  the  tuberculins  might  be 
used,  since  the  protein  substance  of  the  tubercle  bacillus,  the 
ingredient  of  tuberculin  responsible  for  the  reaction,  is  present 
in  all  of  them,  although  in  variable  quantity. 

Selection  of  the  Tuberculin.— I  employ  Koch's  old  tuberculin 
and  this  is  the  one  used  by  the  majority  of  men  engaged  in  work 
on  tuberculosis.  Its  use  is  more  familiar  and  more  study  of  it  in 
regard  to  dosage  has  been  done  than  with  other  preparations. 
Bovine  tuberculin  is  less  desirable  than  human.  Sometimes  a 
patient  will  react  to  one,  and  not  to  the  other,  or  to  the  two  with 
a  different  severity  of  reaction.  A  reaction  to  either  should  be 
considered  positive. 

The  making  of  the  dilutions  is  a  simple  procedure  and  should 
occasion  no  difficulty.  If  one  is  using  tuberculin  for  either 
diagnosis  or  treatment,  he  should  make  his  dilutions  fresh  at  the 
tune  of  injection.  For  those  who  do  not  regularly  employ 
diagnostic  tuberculin,  proper  dilution  may  be  obtained  in  am- 
poules. I  do  not  advise  the  use  of  the  latter,  or  of  tuberculin 
solutions  that  have  been  kept  for  longer  than  two  weeks,  as  such 
dilutions  unquestionably  become  less  active  and  are,  therefore, 
unreliable.  The  original  tuberculin  can  be  kept  for  many  months, 
even  after  unsealing  the  package.  This  is  especially  true  of 


DIAGNOSIS  133 

Koch's  old  tuberculin.  Any  solution  showing  turbidity  should 
not  be  used. 

For  making  dilutions  a  pipette  or  glass  syringe  accurately  grad- 
uated in  tenths  of  cubic  centimeters  is  essential.  As  a  diluent  I 
use  sterile  distilled  water.  To  secure  proper  dosage  two  solutions 
should  be  made.  The  first  is  a  i  :ioo  dilution  made  by  the  addi- 
tion of  0:1  cc.  of  old  tuberculin  to  9.9  cc.  of  diluent;  0:1  cc.  of  this 
dilution  contains  i  mg.  (o.ooi  gm.)  of  tuberculin.  By  the  addi- 
tion of  a  l/2%  of  phenol  this  dilution  will  keep  for  months  and 
can  be  used  for  the  basis  of  future  dilutions.  For  the  second 
dilution  o.i  cc.  of  the  first  solution  is  added  to  0.9  cc.  of  diluent. 
This  makes  a  i  :iooo  solution  of  tuberculin,  o.i  cc.  of  which  con- 
tains i/io  mg.  (o.oooi  gm.).  From  one  of  these  two  dilutions 
any  desired  dosage  can  readily  be  prepared. 

Time  for  Injection. — There  is  a  difference  of  opinion  as  to  the 
most  suitable  time  for  injection.  Some  prefer  giving  the  dose  late 
at  night.  On  the  other  hand,  others  prefer  the  early  morning 
hours,  fearing  that  the  reaction  may  occur  unnoticed  if  the  in- 
jection is  given  at  night. 

Dosage  to  be  used  for  Diagnosis. — As  in  the  administration  of 
remedial  agents,  the  dosage  of  tuberculin  injected  for  diagnostic 
purposes  will  vary  with  the  age  and  vigor  of  the  patient,  and  with 
the  type  of  tuberculous  lesion.  Koch's  suggestion  was  to  give 
at  intervals,  three  doses,  a  first  of  i  milligram,  a  second  of  5 
milligrams,  and  a  third  of  10  milligrams;  the  latter  dose  to  be 
repeated  in  case  of  no  reaction.  By  reason  of  the  fear  attendant 
on  the  use  of  tuberculin  these  doses  have  been  considered  as  too 
large,  and  practically  all  clinicians  make  use  of  smaller  ones. 
Personally,  I  prefer  the  injection  of  much  smaller  doses. 

Diagnostic  Doses  of  Tuberculin  for  the  Subcutaneous  Test 

Age  ist  Dose  2nd  Dose 

Up  to  5  years  i/ioo  mg.  1/80  mg. 

5  -10  years  1/80     "  1/60    " 

10-15     "  1/40     "  1/30    " 

15-20     "  1/20     "  i/io    " 

Adult  i/io     "  i/5      " 

For  a  child  then  under  five  years  I  begin  with  i/ioo  mg.    If 


i34      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

no  reaction — focal,  general  or  local — occurs  in  seventy-two  hours, 
I  increase  the  dose  to  1/80  mg.  In  younger  children  I  stop  with 
the  second  dose,  in  older  children  and  adults  a  third  dose  may 
be  given  which  then  should  be  the  next  larger  one  in  the  above 
scale.  For  an  adult  as  an  average  initial  dose,  I  give  i/io  mg. 
increasing  at  seventy-two  hour  intervals  to  1/5  mg.  and  i  mg. 
if  necessary. 

Small  Doses  Preferable. — I  consider  these  smaller  doses  as 
sufficient,  and  believe  that  conservatism  should  be  the  watch- 
word in  the  use  of  tuberculin  for  diagnostic  purposes.  Experience 
teaches  me  that  a  vigorous  reaction  often  follows  a  slight  increase 
in  dosage  or  even  the  repetition  of  the  same  dose,  which  on  a 
previous  administration  resulted  in  no  reaction.  When  larger 
quantities  of  tuberculin  are  injected,  the  reaction  to  the  repeated 
and  larger  doses  may  be  severe,  and  while  I  believe  no  harm  ever 
results  from  tuberculin  when  used  by  physicians  experienced 
in  its  use,  the  severer  reactions  cause  considerable  discomfort, 
and  I  consider  a  marked  rise  in  temperature  as  unnecessary. 
No  hard  and  fast  rules  can  be  laid  down  for  the  determination 
of  dosage  in  each  individual  case.  The  age  and  vigor  of  the  in- 
dividual, and  the  probable  state  of  activity  of  the  tuberculous 
lesion  must  be  taken  into  consideration.  One's  clinical  experience 
is  the  most  valuable  aid  in  the  determination  of  dosage.  Some 
observers  advise  the  repetition  of  a  small  dose  without  increase. 
Thus  LOWENSTEIN  proposed  not  to  increase  the  dose  at  all,  but 
to  repeat  a  dose  of  2/10  mg.  four  times  in  ten  or  twelve  days.8 
Argument  has  been  raised  by  some  against  the  repetition  of 
dosage  on  the  ground  that  the  reaction  following  a  third  or  fourth 
injection  is  due  to  the  protein  instead  of  a  reaction  due  to  the 
immune  bodies  resulting  from  a  focus  of  tuberculosis.  WOLFF- 
EISNER  considers  this  a  distinct  objection.  Theoretically  it  is 
possible  that  anaphylaxis  might  be  caused  by  the  proteins  con- 
tained in  the  tuberculin  and  account  for  the  reaction  occurring 
on  subsequent  injection  without  tuberculous  infection  being 
present.  But  the  amount  of  foreign  protein  injected  is  so  small 
that  the  production  of  hypersensibility  in  this  manner  is  quite 
improbable.  Those  who  use  this  method,  however,  find  that 


DIAGNOSIS  135 

the  non-tuberculous  react  only  after  many  more  repetitions  of 
dosage  than  are  necessary  to  cause  a  reaction  in  the  tuberculous. 
For  practical  purposes,  therefore,  the  dose  may  be  repeated  and 
increased  as  indicated  without  detracting  from  the  specificity  of 
the  test  in  indicating  the  presence  of  tuberculous  infection. 
From  a  theoretical  standpoint,  an  initial  dose  of  tuberculin  large 
enough  to  cause  a  reaction  is  to  be  preferred  to  repeated  smaller 
doses.  But  the  determination  of  such  dose  is  manifestly  im- 
possible with  any  great  degree  of  accuracy.  Having  in  mind  the 
avoidance  of  severe  reactions  and  great  discomfort  to  the  patient, 
smaller  doses,  repeated  as  is  necessary,  are  for  practical  purposes, 
not  only  permissible  but  to  be  advised.  Other  observers  make 
use  of  and  advise  larger  doses  than  I  employ.  Thus  POTTENGER  9 
recommends  as  an  initial  dose  for  an  average  adult  i  milligram. 
Two  days  later,  if  there  is  no  reaction,  he  gives  3  to  5  milligrams 
and  three  days  later,  in  case  of  no  reaction,  7  to  10  milligrams. 
BANDELJLER  and  ROEPKE  10  regard  an  initial  dose  of  i  milligram 
as  unnecessarily  large  and  recommend  that  the  initial  dose  be 
fixed  at  2/10  milligrams  (0.0002  gm.).  If  no  reaction  occurs 
with  the  first  dose,  a  second  and  larger  one  may  be  given  but  not 
until  the  lapse  of  at  least  forty-eight  hours  to  avoid  the  recurrence 
of  a  late  reaction. 

Maximum  Dose. — It  is  obviously  quite  impossible  to  fix  a 
definite  maximum  dose  for  the  determination  of  the  presence  of 
tuberculosis  or  infection,  a  dose  below  which  the  tuberculous 
individual  will  react  and  the  healthy  will  not.  The  human 
body  is  a  variable  quantity,  no  two  individuals  in  health  being 
alike,  and  still  greater  differences  are  imposed  when  conditions 
of  disease  exist.  Koch  recommended  as  a  maximum  dose  10 
milligrams,  which  he  repeated  once  for  the  sake  of  greater  cer- 
tainty. As  with  the  determination  of  the  initial  dose,  all  factors 
in  any  given  case  should  be  taken  into  consideration.  An  average 
frequently  quoted  is  5  milligrams  for  a  child,  7  milligrams  for  an 
adult  in  lowered  vitality,  and  10  milligrams  for  a  vigorous  adult. 
As  previously  noted  I  consider  such  maximum  doses  as  too  large. 

The  Reaction. — With  the  subcutaneous  test  the  reaction  is 
fourfold  and  may  be  discussed  under  the  following  headings: 


136      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

i  st.  The  febrile  reaction,  consisting  of  a  rise  in  temperature  to 
a  variable  degree; 

2nd.  The  general  or  constitutional  reaction,  comprising  the 
toxic  symptoms  accompanying  a  rise  in  temperature; 

3rd.  The  local  inflammatory  reaction,  at  the  site  of  injection; 

4th.  The  focal  reaction,  occurring  in  the  focus  of  disease. 

The  Febrile  Reaction. — The  rise  in  temperature  is  the  most 
regular  symptom  of  reaction  to  tuberculin  as  applied  in  this  test, 
and  the  one  commonly  depended  upon.  It  can  be  measured 
accurately  and  objectively  with  the  thermometer.  A  certain 
interval  of  time  elapses  between  the  time  of  injection  and  the 
appearance  of  fever  or  other  symptoms.  This  constitutes  the 
incubation  period,  and  is  the  time  in  which  the  specific  antibodies 
are  engaged  in  breaking  up  the  tubercle  bacillus  proteid,  and 
liberating  its  toxic  portion. 

Time  of  Reaction. — The  time  of  reaction  begins  usually  10  to 
16  hours  after  the  injection  of  tuberculin.  In  rare  instances  it 
begins  in  3  to  4  hours  or  may  be  delayed  two  or  three  days.  The 
temperature  may  show  a  rise  of,  only  a  fraction  of  a  degree,  but 
such  should  arouse  suspicion  and  be  considered  evidence  of  a 
reaction,  if  there  are  concomitant  general  symptoms  or  a  local 
reaction.  In  a  mild  reaction  the  temperature  reaches  100°  F. 
In  severe  ones  it  reaches  or  may  exceed  102°  F.  The  reaction 
ordinarily  reaches  its  height  within  24  to  48  hours  after  the  time 
of  injection  and  then  gradually  falls,  reaching  the  normal  in  24 
to  48  hours  except  in  the  most  severe  responses.  The  febrile 
reaction  is  subject  to  variation  and  no  typical  temperature  curve 
can  be  described. 

Variations  in  Reaction. — There  is  usually  a  more  or  less  rapid 
rise,  followed  by  a  more  gradual  fall  to  the  normal.  In  inter- 
preting the  reaction,  increase  of  the  temperature  due  to  inter- 
current  infections,  menstrual  fevers,  and  the  like,  must  be  ex- 
cluded. In  neurotic  individuals  a  febrile  reaction  may  some- 
times follow  the  needle  puncture  alone.  If  such  is  suspected, 
it  may  be  eliminated  by  giving  sterile  water  at  the  first  injection. 

Constitutional  Reactions.— The  general  symptoms  are  toxic 
in  origin  and  resemble  those  occurring  with  the  toxemia  of  bac- 


DIAGNOSIS  137 

terial  infection.  The  patient  suffers  from  malaise,  loss  of  strength, 
increased  nervousness  and  anorexia.  They  feel  "achy"  and  de- 
pressed, and  complain  of  headache  and  soreness  in  the  muscles. 
In  more  severe  reactions  the  nervousness  is  marked,  and  severe 
headache,  pain  in  the  back  and  limbs,  chills  and  vomiting  may 
be  noted.  The  symptoms  resemble  those  of  the  onset  of  an  acute 
infectious  disease.  They  are  usually  in  proportion  to  the  extent 
of  the  rise  in  temperature,  but  may  be  well  marked  in  cases  with 
only  a  slight  or  even  a  negative  febrile  reaction.  In  such  cases 
they  are  characteristic  and  indicative  of  a  reaction.  When  the 
general  symptoms  are  noted  and  properly  interpreted,  there  is  no 
necessity  for  the  production  of  such  great  febrile  reactions.  The 
general  symptoms  usually  subside  quickly,  but  in  very  severe 
reactions  prostration  may  persist  for  several  days.  In  such  an 
event  the  patient  should  be  confined  to  bed. 

The  Local  Reaction. — The  local  reaction  consists  of  congestion 
and  infiltration  at  the  site  of  injection.  Like  the  febrile  reaction 
it  varies  in  the  degree  of  its  severity,  and  usually  quickly  sub- 
sides. In  case  the  temperature  is  increased  only  a  part  of  a 
degree,  the  occurrence  of  a  local  reaction  is  confirmatory  to  the 
doubtful  febrile  reaction. 

The  Focal  Reaction. — The  production  of  a  focal  reaction  is  the 
distinguishing  characteristic  of  the  subcutaneous  test.  It  is 
also  a  most  important  characteristic  and  one  not  observed  in 
the  other  tuberculin  tests,  which  fact  gives  the  subcutaneous 
test  superiority  as  a  diagnostic  measure.  The  focal  reaction  con- 
sists in  an  inflammatory  process  in  the  tuberculous  focus  with 
the  production  of  symptoms  and  signs  of  disease,  thus  enabling 
one  to  determine  the  site  of  infection.  In  superficial  lesions, 
such  as  lupus  or  tuberculous  glands,  a  focal  reaction  is  very 
evident.  When  the  lesions  are  situated  internally,  unfortunately 
the  reactions  are  often  not  definite  enough  to  be  convincing,  and 
in  their  absence  it  cannot  be  concluded  that  no  focal  reaction 
has  occurred.  The  symptoms  will  vary  with  the  location  and 
extent  of  the  disease.  In  order  to  recognize  a  focal  reaction,  a 
careful  physical  examination  previous  to  the  application  of  the 
test  is  essential. 


i38      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

Negative  Reactions. — Negative  tuberculin  reactions  are  ob- 
served in  various  acute  diseases,  notably  measles,  scarlet  fever, 
influenza  and  less  often  in  diphtheria,  pneumonia  and  others; 
negative  results  are  also  observed  in  some  cases  of  manifest 
tuberculosis,  miliary  tuberculosis  and  tuberculous  meningitis. 
SAHLI  "  offers  the  following  possible  explanations  for  such  neg- 
ative reactions: 

1.  The  body  may  contain  such  an  excess  of  lysinized  tuberculin 
that  the  extra  amount  does  not  display  any  action. 

2.  The  tissues  may  be  so  damaged  that  they  produce  no  lysin. 

3.  The  lysin  may  be  so  far  neutralized  that  the  injected  tuber- 
culin finds  no  free  lysin  to  act  upon  and,  therefore,  proves  in- 
active. 

Specificity  of  the  Test. — The  specificity  of  the  tuberculin 
reactions,  as  an  evidence  of  tuberculous  infection,  can  hardly  be 
contested  at  the  present  time.  The  occurrence  of  positive  reac- 
tions in  apparently  healthy  individuals,  and  in  various  conditions 
of  disease,  was  formerly  considered  as  evidence  against  the  test 
as  a  specific  one.  The  demonstration  of  the  great  frequency  of 
latent  tuberculous  foci  by  the  autopsy  findings  of  numerous 
observers,  leaves  little  doubt  but  what  a  tuberculous  infection 
is  present  whenever  the  reaction  is  positive.  Its  occurrence  in 
disease,  such  as  syphilis,  may  be  explained  by  the  existence  of  a 
focus  of  infection,  since  it  is  not  found  to  be  positive  in  all  cases. 
That  positive  reactions  in  leprosy  may  be  due  to  a  group  reaction 
is  a  very  probable  suggestion,  when  we  consider  the  similarity  of 
the  bacilli  of  tuberculosis  and  leprosy,  both  in  their  morphological 
characteristics  and  in  the  type  of  lesions  which  they  produce. 
Others  have  sought  to  disprove  the  specific  character  of  the  reac- 
tion by  claiming  that  reactions  may  be  obtained  in  tuberculosis 
by  the  injection  of  indifferent  substances  such  as  albumen  and 
peptone.  But  the  specificity  of  tuberculin  is  to  be  maintained 
by  reason  of  the  fact  that  relatively  large  amounts  of  these  in- 
different substances  are  required  to  produce  a  reaction,  while 
minute  amounts  of  tuberculin  suffice.  The  reaction  with  tuber- 
culin is  not  due  to  its  albumose  content,  for  reactions  are  ob- 
tained with  albumose  free  preparations. 


DIAGNOSIS  139 

Dangers  of  the  Test. — The  subcutaneous  test  is  held  in  fear 
by  many  by  reason  of  the  unfavorable  results  obtained  with  the 
use  of  tuberculin  when  it  was  first  introduced.  Such  unfavorable 
results  must,  however,  be  attributed  to  its  improper  use.  There 
are  those  who  consider  that  the  focal  reaction,  attended  by  con- 
gestion and  exudation  in  the  focus  of  infection,  may  lead  to  a 
spread  of  the  disease.  SAHLI  12  in  speaking  of  diagnostic  injec- 
tions says:  "I  consider  the  risk  attending  their  use  sufficient  for 
their  rejection."  In  contrast  to  such  views  is  the  experience  of 
the  vast  majority,  who  have  used  tuberculin  to  any  extent. 
All  those  who  have  had  a  wide  experience  state  that  when  prop- 
erly administered,  tuberculin  does  not  cause  extension  of  the 
disease.  On  many  occasions  have  I  seen  marked  improvement 
following  a  diagnostic  injection,  and  when  given  as  I  have  in- 
dicated, I  have  never  seen  harm  result.  POTTENGER  makes  the 
following  significant  statement:  "The  frequency  with  which 
patients,  who  have  been  suffering  from  an  active  tuberculosis, 
improve  following  a  reaction  produced  for  the  purpose  of  di- 
agnosis will  more  than  offset  any  supposed  harm  that  might  have 
resulted  in  other  cases.  Any  one  who  has  had  such  experience 
in  the  employment  of  the  subcutaneous  test  must  have  observed 
this." 

Contraindications  to  the  Subcutaneous  Test. — There  are 
several  contraindications  to  the  subcutaneous  test.  It  is  an  un- 
necessary procedure,  and  because  of  the  discomfort  to  the  patient 
which  it  may  occasion,  it  should  not  be  employed,  when  the  ev- 
idence obtained  from  the  physical  findings  or  the  demonstration 
of  the  tubercle  bacillus  leaves  no  doubt  as  to  the  diagnosis. 
The  existence  of  fever  of  100°  F.  would  mask  a  reaction  and, 
therefore,  contraindicate  its  use.  It  should  not  be  used  in  pul- 
monary tuberculosis  following  a  recent  hemoptysis  as  the  reac- 
tion may  be  negative  at  such  time.  Disease  of  various  organs 
constitutes  relative  contraindications.  We  should  consider  severe 
valvular  lesions,  and  advanced  myocardial  degeneration  as  indi- 
cations for  its  non-use.  Severe  nephritis  likewise  contraindicates. 
It  should  not  be  employed  in  cases  of  miliary  tuberculosis,  tuber- 
culous meningitis,  or  during  convalescence  from  severe  disease 


i4o      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

such  as  scarlet  fever,  measles,  influenza,  typhoid  or  pneumonia, 
as  it  may  be  negative  even  in  the  presence  of  tuberculous  infec- 
tion, and  hence  could  not  be  of  any  value.  Since  it  has  been 
known  to  aggravate  cases  of  epilepsy,  it  should  not  be  used  in 
individuals  so  addicted.  Severe  diabetes  and  marked  arterio- 
sclerosis contraindicate  its  use.  The  cutaneous  test  should  be 
applied  in  such  cases. 

Interpretation  of  Tuberculin  Reactions. — In  interpreting 
tuberculin  reactions,  it  must  be  remembered  that  a  positive 
reaction  is  but  an  indication  of  the  presence  in  the  organism  of 
specific  immune  bodies,  whether  they  are  considered  as  an- 
aphylactins  or  lysins.  Since  these  bodies  may  be  present  as  the 
result  of  lesions  which  are  inactive,  and  constitute  infection  but 
not  disease,  it  is  evident  that  the  value  of  the  tests  must  always 
be  more  or  less  relative. 

Test  May  Determine  Activity  or  Inactivity. — I  have  con- 
sidered the  value  of  the  v.  Pirquet  test  in  childhood  and  its  in- 
terpretation. In  my  opinion  the  subcutaneous  test  must  be  ad- 
mitted to  be  the  superior  test  in  older  children  and  adults  from 
the  standpoint  of  diagnostic  value,  since  in  it  we  know  the  def- 
inite amount  of  tuberculin  introduced  and  are  assured  of  its 
absorption.  The  occurrence  of  a  focal  reaction  is  likewise  an 
important  characteristic  possessed  only  by  the  subcutaneous 
test.  We  are  interested  in  tuberculous  disease  rather  than  in 
tuberculous  infection.  The  drawbacks  to  the  usefulness  of  the 
tuberculin  test  lie  in  its  delicacy  in  indicating  hypersensitiveness, 
and  in  the  fact  that  nearly  every  individual  has,  at  some  time  in 
his  life,  had  a  tuberculous  infection.  That  hypersensitiveness 
varies  must  be  admitted.  My  personal  experience  teaches  me 
that  there  is  a  very  noticeable  difference  in  the  reactions  occurring 
in  active  disease,  and  in  latent  infections.  In  general  we  may 
say  that  prompt  and  vigorous  reaction  to  small  doses  is  in- 
dicative of  active  lesions,  and  sluggish  and  delayed  reactions  or 
to  larger  and  repeated  doses  indicate  latent  infections.  All  who 
have  had  much  experience  with  tuberculin  must  have  noted  this 
fact.  But  there  are  many  intervening  degrees  of  reactivity  diffi- 
cult of  interpretation,  and  the  dividing  line  between  active  and 


DIAGNOSIS  141 

latent  tuberculous  foci  is  by  no  means  sharply  drawn.  In  such 
cases  the  occurrence  of  a  focal  reaction  may  be  of  great  assistance, 
especially  in  cases  with  superficial  lesions,  or  in  surgical  tuber- 
culosis so-called. 

Value  of  Experience  With  the  Tests. — The  more  familiar  one 
is  with  the  use  of  tuberculin,  the  better  able  one  will  be  to  judge 
reactions,  and  interpret  them  properly  in  the  individual  case. 
While  admitting  the  difficulty  in  interpreting  reactions  in  doubt- 
ful cases,  I  must  agree  with  BANDELIER  and  ROEPKE  when  they 
say — "It  would,  however,  be  a  crime  against  the  spirit  of  di- 
agnosis to  let  what  has  been  said  prove  an  insurmountable  barrier 
to  the  use  of  tuberculin  in  diagnosis." 

In  case  of  tuberculosis  of  superficial  glands  in  which  the  di- 
agnosis is  doubtful,  the  subcutaneous  test  may  be  employed  and 
the  occurrence  of  a  focal  reaction  easily  determined.  When 
such  occurs  the  glands  show  an  inflammatory  reaction  to  a 
variable  degree.  In  addition  to  the  febrile  and  general  reaction 
the  affected  nodes  become  tender  to  the  touch  and  spontaneous 
pain  may  be  complained  of.  In  well-marked  reactions  the  glands 
may  become  appreciably  enlarged.  If  the  skin  has  become  ad- 
herent it  may  become  reddened.  If  sinuses  are  present,  the  dis- 
charge from  them  may  be  increased  in  amount.  With  the  sub- 
sidence of  the  reaction,  improvement  usually  is  noted.  This 
applies  to  tuberculous  cervical  glands  so  commonly  noted,  and 
also  to  infections  of  the  axillary  inguinal  or  other  superficial 
nodes. 

Interpretation  of  Tests. — Latent  infections  of  the  bronchial 
nodes  are  a  frequent  cause  of  positive  reactions  in  those  who 
clinically  are  non-tuberculous.  As  noted  above,  I  consider  the 
character  of  the  reactions  as  an  important  indication  of  the 
activity  of  the  lesion,  active  lesions  responding  promptly  and 
reaching  a  maximum  early,  while  less  active  or  latent  infections 
result  in  reactions  which  respond  less  promptly  and  less  vigor- 
ously, and  may  require  a  repetition  of  the  dose  of  tuberculin. 
Tuberculous  infection  of  these  nodes,  which  is  active  and  pro- 
ducing pressure  symptoms,  may  respond  with  a  focal  reaction 
characterized  by  an  exaggeration  of  these  symptoms.  In  cases 


i42      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

with  toxic  symptoms,  but  no  pressure  symptoms,  the  latter  may 
appear  temporarily  as  the  result  of  a  focal  reaction.  With  the 
subsidence  of  the  reaction  an  improvement  is  seen,  and  not  in- 
frequently have  I  noted  reactions,  provoked  for  the  purpose  of 
confirming  a  diagnosis,  prove  to  be  the  turning  point  in  the  course 
of  the  disease  with  marked  improvement  and  even  apparent  re- 
covery following.  For  these  reasons  I  do  not  hesitate  to  employ 
the  subcutaneous  test  as  a  means  of  diagnosis  and  when  used, 
as  I  have  directed,  it  can  result  in  no  harm  and  often  has  a  most 
beneficial  effect. 

Complement  Fixation  Test. — The  complement  fixation  test 
which  has  proven  to  be  of  so  much  value  in  the  diagnosis  and  con- 
trol of  treatment  in  syphilis,  has,  in  recent  years,  been  applied 
along  similar  lines  in  the  diagnosis  of  tuberculosis.  The  results 
reported  thus  far  are  somewhat  conflicting  and  more  work  is 
needed,  both  in  the  laboratory  and  in  clinical  application  of  the 
test,  before  it  can  be  placed  upon  a  thoroughly  practical  basis 
and  generally  accepted  as  a  routine  diagnostic  measure.  The 
conflicting  statements  regarding  the  test  are  evidently  due,  in 
large  part,  to  the  fact  that  various  workers  with  the  test  make 
use  of  different  antigens. 

Value  of  Different  Antigens. — BESREDKA  13  using  an  antigen 
prepared  from  culture  grown  in  egg  bouillon  obtains  about  90% 
of  positive  results,  being  definite  cases  of  tuberculosis,  but  the 
value  of  these  observations  is  impaired  by  the  fact  that  syphilitic 
cases  would  also  give  positive  results.  MC!NTOSH  and  FILDES  14 
use  as  an  antigen  a  freshly  prepared  emulsion  of  the  bacilli  in 
saline;  they  grow  the  bacilli  used  in  preparing  their  antigen  on 
glycerin  egg  medium.  They  quote  the  following  results: 

Cases  Positive  Percentage 

Phthisis  43  33  ?6.7 

Surgical  tuberculosis  exclusive  of  glands          26  21  80.7 

Tuberculous  Glands  16  6  37.5 

Eighty-seven  control  cases,  taken  from  a  variety  of  disease 
conditions  in  addition  to  normal  individuals,  were  negative  with 
the  exception  of  three.  Two  of  these  were  cases  of  leprosy  in 
which  the  reaction  may  be  explained  as  a  ''Group  reaction." 


DIAGNOSIS  143 

The  other  was  a  case  of  Addison's  disease  in  which  tuberculosis 
is  a  frequent  etiological  factor.  They  tested  the  sera  of  eighteen 
syphilitics  with  positive  Wasserman  tests  and  all  gave  a  negative 
reaction.  With  tuberculin  as  an  antigen  syphilitics  frequently 
react.  They  conclude  that  the  lesion  must  be  of  considerable 
size  and  constitute  disease  before  it  will  give  a  reaction.  "We 
look  upon  the  positive  reaction  therefore  as  indicating  positive 
tuberculosis."  If  such  proves  to  be  the  case  the  complement 
fixation  test  will  be  of  great  value  in  diagnosis. 

BRONFENBRENNER  15  uses  Besredka's  antigen.  He  concludes 
that  the  reaction  is  not  lipotropic  in  nature.  "When  the  serum 
deviates  the  complement  in  the  presence  of  both  Besredka's 
antigen  and  pure  lipoid  antigen,  each  of  the  two  antigens  can  be 
exhausted  from  the  serum  independently  of  the  other."  He  finds 
that  the  antigen  does  not  lose  its  antigenic  properties  when 
freed  of  its  lipoid  substances.  The  evidence  he  brings  forth 
points  to  the  evident  specificity  of  the  test.  He  obtained  93.84% 
of  positive  reactions  in  active  tuberculosis. 

Craig's  Polyvalent  Antigen.— CRAIG  16  uses  a  polyvalent  an- 
tigen prepared  from  several  strains  of  bacilli.  He  finds  com- 
plement binding  bodies  present  in  blood  serum  of  individuals 
with  either  clinically  active  or  inactive  tuberculosis.  He  ob- 
tained positive  reactions  in  96.2%  of  cases  of  active  and  66.1% 
of  inactive  tuberculosis.  He  found  the  test  negative  in  normal 
individuals  and  not  positive  in  syphilitics,  if  no  tuberculosis  was 
present.  He  concludes  that,  when  positive,  it  is  specific. 

The  complement  fixation  test  may  be  negative  in  advanced 
cases  of  tuberculosis.  Tuberculin  tests  are  also  often  observed 
to  be  negative,  in  such  cases  indicating  the  absence  of  immune 
bodies  from  the  serum  of  individuals  so  afflicted.  The  reaction 
may  also  be  positive  for  some  time  after  a  lesion  has  become 
quiescent  and  inactive,  as  determined  by  the  history  and  symp- 
tomatology. 

Considering  the  limited  amount  of  work,  which  has  been  done 
in  this  test,  it  is  promising  and  deserves  further  study  and  trial. 

The  Agglutination  Test. — ARLOING  employed  the  agglutina- 
tion method,  based  on  the  GRUBER-WIDAL  reaction  as  used  in 


144      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

typhoid,  for  the  diagnosis  of  tuberculosis.  In  the  case  of  tubercle 
bacilli  it  is  difficult  to  make  sure  of  agglutination.  They  grow 
slowly,  and  spontaneously  occur  in  groups.  Such  cultures  can- 
not be  used  in  determining  whether  or  not  agglutination  has  oc- 
curred. In  the  test  cultures,  known  as  homogeneous  cultures 
obtained  by  special  technique,  are  employed.  In  such  cultures 
the  bacilli  lie  singly  and  are  capable  of  agglutination  or,  more 
properly  speaking,  precipitation.  The  method  has  been  employed 
by  Arloing  and  others,  the  course  of  procedure  is  too  complicated 
for  ordinary  use,  the  results  are  not  sufficiently  reliable  for  prac- 
tical purposes,  and  the  method  is  little  used  at  present. 

KTNGHORN  and  TWITCHELL  17  found  that  the  blood  serum  of 
healthy  individuals  agglutinated  the  tubercle  bacilli  almost  as 
frequently  as  did  the  serum  of  patients  suffering  from  pulmonary 
tuberculosis.  They  noted  agglutination  in  84.28%  of  healthy, 
as  compared  with  87.09%  of  tuberculous  individuals. 

Various  other  tests  have  been  proposed  from  time  to  time  but 
they  have  proven  to  be  of  little  value  in  diagnosis.  Wright's 
opsonic  index  is  of  no  practical  value.  Arneth's  blood  picture 
was  never  advanced  as  a  diagnostic  method,  but  only  as  an  aid 
in  prognosis. 


CHAPTER  IX 
TREATMENT 

Prophylaxis. — In  dealing  with  the  treatment  of  any  disease  our 
first  aim  should  be  prophylaxis  and  prevention.  Especially  is 
this  to  be  desired  in  a  disease  so  prevalent  and  claiming  so  many 
victims  as  does  tuberculosis,  the  treatment  of  which  is  tedious 
and  often  unsatisfactory.  Prophylactic  measures  have  proven 
inefficient  in  the  past  and  are  in  need  of  revision.  The  measures 
employed  should  vary  with  the  object  aimed  at,  as  the  prevention 
of  infection  and  the  protection  of  adults  and  children  differ. 

The  prevention  of  infection  in  infancy  demands  our  first  atten- 
tion. Children  are  born  free  from  tuberculosis,  congenital  in- 
fection being  very  rare,  even  if  the  parents  were  tuberculous  at 
the  time  of  conception  and  birth  of  the  child.  But  many  infants 
are  infected  during  the  first  year  of  life  and  with  increasing  age 
the  number  increases,  as  can  be  demonstrated  by  the  reaction 
to  tuberculin,  until  at  the  age  of  14  years,  over  90%  of  all  in- 
dividuals have  had  a  tuberculous  infection.  Tuberculosis  is  a 
very  dangerous  disease  in  infants  who  exhibit  but  little  resistance 
to  it.  During  the  first  two  years  of  life  infection  is  likely  to  result 
in  an  acute  or  subacute  disease  which  proves  fatal  in  nearly  all 
cases.  After  infancy  it  becomes  less  dangerous  and  less  often 
causes  death  although  it  may  localize  in  the  glands  or  bones  and 
cause  a  prolonged  period  of  ill  health  and  perhaps  disfigurement. 
In  combating  infantile  tuberculosis  we  should  aim  at  the  pre- 
vention of  infection  and  at  the  increase  of  the  powers  of  resistance 
of  the  body.  Because  of  the  fatality  of  infantile  tuberculosis, 
it  is  clear  that  our  aim  should  be  to  protect  infants  under  two 
years  of  age  from  infection,  and  to  subject  older  children  to  the 
contagion  of  the  tubercle  bacillus  as  rarely  and  as  late  in  life  as 
possible.  This  is  a  simple  matter  in  families,  in  which  there  is  no 
tuberculous  member,  but  a  difficult  problem  presents  itself, 


i46      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

when  the  child  is  exposed  to  infection  by  contact  with  members 
of  his  own  immediate  family,  who  are  suffering  from  the  disease. 
Children  Must  be  Removed  from  the  Infected. — No  infant 
should  be  allowed  to  remain  in  a  home  with  an  individual  suffering 
from  phthisis.  Either  the  infected  individual  or  the  infant  must 
be  removed.  Even  consumptives,  who  are  cleanly,  and  are  careful 
about  the  disposal  of  their  sputum,  and  of  little  or  no  danger  to 
adults,  are  dangerous  to  the  susceptible  infant.  Special  diffi- 
culties are  encountered  when  one  of  the  parents  has  tuberculosis. 
The  tuberculous  individual  who  marries  and  has  a  family  takes 
upon  himself  a  great  responsibility.  Individuals,  whose  tuber- 
culosis is  not  positively  healed,  should  be  encouraged  not  to 
marry.  If  they  do  so  they  should  be  informed  of  the  dangers 
their  children  would  be  subjected  to,  and  procreation  should 
not  be  permitted,  unless  they  are  willing  to  have  their  children 
removed  from  them  for  two  years  after  birth,  a  wish  rarely  com- 
plied with.  From  animal  experiments  we  may  infer  that  children 
so  cared  for  will  be  healthy.  HESS  l  has  called  attention  to  the 
neglect  to  provide  for  the  welfare  of  the  infants  born  of  tuber- 
culous parentage  and  urges  that,  in  the  light  of  our  present 
knowledge  as  to  the  time  when  infection  occurs  and  the  fatality 
of  infantile  tuberculosis,  our  methods  of  prophylaxis  be  recon- 
structed. No  tuberculous  mother  should  be  allowed  to  rear  her 
children  at  least  during  infancy,  for  very  few  survive  when 
nursed  by  such  a  mother.  After  delivery  the  child  should  be 
removed  to  surroundings,  where  it  will  not  be  subjected  to  the 
dangers  of  infection,  and  should  not  be  permitted  in  the  proximity 
of  the  tuberculous  mother  for  the  first  two  years  of  life.  Hess 
advised  the  establishment  of  preventoriums  for  infants  where 
they  should  receive  adequate  care.  It  is  rarely  that  such  radical 
wishes  are  complied  with,  for  mothers  will  not  part  with  their 
children,  unless  they  are  in  the  last  stages  of  the  disease.  Many 
such  mothers  have  the  care  of  their  household  and  cannot  be 
spared.  Likewise,  the  tuberculous  father  may  be  a  menace 
but  cannot  be  spared  and  removed  to  a  sanitorium,  for  he  may 
be  the  only  source  of  income.  If  the  infant  cannot  be  removed 
from  the  house,  the  most  painstaking  precautions  must  be  ob- 


TREATMENT  147 

served  and,  so  far  as  possible,  it  should  be  isolated  from  the  in- 
fected individual.  Whenever  possible  the  care  of  the  infant 
should  be  entrusted  to  a  healthy  individual  and  when  a  tuber- 
culous mother  is  compelled,  by  necessity,  to  assume  the  personal 
care  of  the  infant  she  should  be  fully  instructed  as  to  the  dangers 
of  the  infection  and  the  means  to  be  adopted  for  preventing  them. 
In  houses  where  there  is  no  tuberculous  individual  the  protection 
of  the  infant  is  an  easier  matter.  Strangers  should  be  forbidden 
to  fondle  children,  and  the  kissing  of  infants  is  particularly  ob- 
jectionable. 

Nurses  and  Servants  Should  be  Examined. — In  selecting  a 
nurse  or  servant  who  comes  into  intimate  association,  tuberculo- 
sis should  be  thought  of  and  anyone  suffering  from  open  tuber- 
culosis should  not  be  permitted  to  mingle  with  children. 

Resistance. — In  addition  the  general  precautions  for  increasing 
the  powers  of  resistance  of  the  body  should  be  observed.  The 
question  of  feeding  is  of  prime  importance  and  whenever  pos- 
sible infants  should  be  breast  fed,  for  such  children  have  greater 
resistance  against  all  infections,  including  tuberculosis.  Only 
in  the  most  incipient  stages  should  a  tuberculous  mother  be 
allowed  to  nurse  her  child  for  the  number  infected  by  contact 
with  mothers  suffering  from  open  tuberculosis  is  very  great. 
The  danger  is  in  contact,  and  not  in  the  transmission  of  infection 
by  the  milk.  Mother's  milk  is  the  ideal  and  safest  food  for  the 
infant.  A  wet  nurse  is  the  next  choice,  but  is  seldom  available, 
and  it  then  becomes  necessary  to  resort  to  artificial  feeding  as 
a  substitute.  One  should  endeavor  for  the  first  few  weeks,  the 
most  serious  time,  to  obtain  nourishment  for  the  child  from  the 
mother  and  then  should  a  change  be  necessary  cow's  milk  prop- 
erly modified  may  be  substituted,  at  first  for  only  one  meal, 
and  then  two  or  three  or  more  may  be  given,  but  breast  milk 
should  always  be  given  as  long  as  possible,  at  least  during  the 
first  six  months  of  life. 

Milk  an  Important  Factor. — When  artificial  feeding  becomes 
necessary  the  dangers  of  bovine  infection  must  be  thought  of. 
Milk  for  infant  feeding  should  be  obtained  from  cattle,  free  from 
tuberculosis  as  demonstrated  by  tuberculin  tests,  and  obtained 


i48      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

from  dairies  where  the  best  of  sanitary  conditions  prevail.  In 
cities  such  milk  is  obtainable  in  the  form  of  certified  milk,  the 
only  drawback  of  which  is  its  rather  high  cost.  Raw  milk  is,  in 
many  ways,  preferable,  but  when  the  source  of  supply  is  un- 
known and  the  methods  of  handling  and  delivery  are  not  beyond 
suspicion  some  method  of  sterilization  is  imperative.  Pasteuriza- 
tion is  the  most  satisfactory  method  and  presents  the  least  ob- 
jections. Intense  heating  of  the  milk  is  undesirable  although 
boiling  is  more  certain.  However,  tubercle  bacilli  are  killed  by 
an  exposure  of  140°  F.  maintained  for  20  minutes,  and  this  tem- 
perature does  not  render  the  milk  unfit  for  use,  or  impair  its 
nutritive  properties. 

Fresh  Air. — Tuberculosis  is  a  house  disease  and  care  should 
be  exercised  in  the  home  to  which  children  are  more  or  less 
closely  confined  for  the  first  years  of  their  life.  Fresh  air,  light, 
and  cleanliness  are  cardinal  demands  to  which  attention  should 
be  paid  for  hygienic  reasons.  Fresh  air  has  an  invigorating  in- 
fluence upon  the  nourishment  of  any  individual.  Air  within 
homes  is  never  so  pure  or  free  from  germs  as  the  open  air  and 
children  should,  therefore,  be  accustomed  to  fresh  air  at  an  early 
age,  avoiding,  of  course,  needless  exposures  and  radical  attempts 
at  hardening.  Sunlight  and  fresh  air  are  the  enemies  of  the 
tubercle  bacillus,  and  homes  should  be  lighted  and  well  ventilated, 
especially  the  nursery.  A  light  airy  home  is  a  more  important 
factor  in  the  life  of  the  child  than  of  the  adult,  whose  activities 
take  him  into  the  open  air  to  a  greater  extent. 

Cleanliness. — Children  and  their  environments  should  be  kept 
clean.  Rooms  in  which  children  live  should  be  cleansed  daily 
and  aired  several  times  a  day,  for  frequent  sunning  and  ventila- 
tion will  help  to  exterminate  any  tubercle  bacilli  that  may  be 
present.  People  in  changing  residence  from  one  place  to  another 
should  always  consieer  the  possibility  of  their  predecessors  having 
had  tuberculosis,  and  should  cleanse  and  disinfect  accordingly. 
Children  old  enough  to  creep  are  especially  liable  to  become  in- 
fected from  contaminated  carpets  and  floors.  Hence,  carpets 
should  be  banished  whenever  possible  and  replaced  by  rugs, 
which  can  more  easily  be  removed  and  thoroughly  cleansed. 


TREATMENT  149 

The  floors  should  be  kept  clean  and  not  trodden  upon  with 
dirty  shoes,  as  creeping  children,  if  allowed  their  freedom,  come 
in  constant  contact  with  them.  It  is  a  good  plan  to  confine  chil- 
dren of  this  age  in  one  part  of  the  room  upon  a  clean  sheet. 
Dry  sweeping  and  dusting  are  to  be  avoided  because  of  the 
dangers  of  dust  infection. 

The  improved  method  of  vacuum  cleansing  is  an  advancement 
and,  when  not  available,  cleansing  of  the  floors  and  removal  of 
dust  should  be  accomplished  by  a  damp  cloth.  The  child's  toys 
should  be  washable  and  frequently  cleansed. 

Dangers  From  Outside  Infection. — In  older  children  the  con- 
tact with  individuals,  outside  the  immediate  family,  makes  the 
prevention  of  all  infection  difficult.  But  the  contact  is  less  in- 
timate and  the  infection  less  massive  and  goes  on  to  healing,  or 
becomes  a  latent  glandular  infection  which  becomes  serious 
only  under  special  circumstances.  The  mortality  of  tuberculosis 
in  older  children  is  slight  and  in  striking  contrast  to  that  in  in- 
fancy. These  mild  infections  act  as  a  vaccination  against  tuber- 
culosis, and  upon  this  probably  depends  the  protection  of  the 
race  from  the  ravages  of  tuberculosis.  Our  object  then  should 
be  to  prevent  all  infection  during  infancy  and  to  prevent  massive 
infection  of  older  children. 

Our  attempts  at  protection  from  tuberculosis  in  older  children 
should  not  be  so  much  directed  against  the  prevention  of  infec- 
tion, which  is  almost  inevitably  acquired,  as  toward  protecting 
them  from  the  consequences  of  what  has  already  occurred  and 
cannot  be  avoided.  The  comparative  harmlessness  of  these  in- 
fections is  evidenced  by  the  fact  that  almost  everyone  has  had 
some  tuberculous  infection,  and  yet  only  a  certain  percentage 
die  of  tuberculosis.  A  dangerous  feature  lies  in  the  fact  that  the 
transition  of  a  harmless  latent  infection  to  tuberculous  disease 
is  so  gradual  that  it  is  usually  overlooked,  until  disaster  has  re- 
sulted. 

Important  to  Examine  all  Children. — In  order  to  recognize 
the  existence  of  tuberculous  disease  in  its  incipiency,  MARY  E. 
LAPHAM  2  recommends  the  medical  examination  of  school  chil- 
dren. She  states  that:  "The  competent  yearly  examination  of 


1 50      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

every  child  in  the  public  schools,  if  not  ruined  by  political  ap- 
pointments, will  detect  the  beginnings  of  tuberculous  processes, 
where  and  when  they  start  in  children,  and  eventually  teach  us 
that  the  danger  from  the  tubercle  bacillus  is  far  more  from  within 
than  from  without.  Infection  does  not  always  cause  tuber- 
culosis, but  if  it  should,  then  the  sooner  we  find  it  out  the 
better." 

Glandular  Infections. — In  preventing  glandular  tuberculosis 
we  must  direct  attention  to  the  mucous  membranes  of  the  re- 
spiratory and  gastro-intestinal  tracts,  which  are  tributary  to  the 
commonly  affected  bronchial,  cervical  and  mesenteric  glands. 
In  the  gastro-intestinal  tract,  we  should  avoid  digestive  disturb- 
ances and  inflammations.  Although  the  tubercle  bacillus  can 
pass  through  a  healthy  mucous  membrane  and  infect  the  ad- 
jacent glands,  the  chances  of  infection  are  greatly  increased  in 
the  presence  of  an  inflammation.  In  this  regard,  overfeeding  of 
infants  with  cows'  milk  is  more  to  be  feared  than  underfeeding. 
The  excess  of  food  passes  through  the  intestinal  tract  undigested 
and  non-used.  Continuous  over  feeding  may  irritate  the  mucous 
membrane  by  the  process  of  decomposition,  and  lead  to  inflamma- 
tion and  swelling  of  the  lymphatic  follicles,  which  favors  gland 
infection  and  lessens  absorption  and  impairs  nutrition.  It  goes 
without  saying,  that  we  must  quickly  relieve  underfeeding  both 
quantitative  and  qualitative.  A  form  of  qualitative  under- 
feeding observed  in  older  children  is  fat  starvation.  Many 
children  presenting  themselves  for  treatment  of  glandular  tuber- 
culosis give  a  history  of  marked  aversion  to  fats.  This  should 
be  combated,  for  fats  are  essential  to  good  nutrition. 

Respiratory  Tract  a  Source  of  Danger. — Attention  must  be 
paid  to  the  respiratory  tract  with  the  view  of  preventing  rein- 
fection from  within  the  body.  Latent  infections  may  lie  dormant 
in  the  bronchial  glands  and  only  become  active  under  special 
circumstances.  Impaired  nutrition  and  lowered  resistance,  in- 
cident to  intercurrent  disease,  seem  to  be  the  most  potent  factors 
in  activating  such  infections  and  causing  tuberculous  disease. 
Young  children  and  infants  are  to  be  protected  from  measles, 
pertussis,  scarlet  fever,  and  other  infectious  diseases,  during 


TREATMENT  151 

which  an  allergic  state  is  known  to  occur.  It  seems  that  the 
younger  the  child  the  more  is  the  allergy  induced  likely  to  be 
followed  by  active  tuberculosis.  Special  care  is  to  be  taken  in 
case  of  children  of  tuberculous  parentage,  for  they  have  prob- 
ably been  subjected  to  a  massive  infection.  If  these  infectious 
diseases  do  occur,  children  should  be  guarded  against  them  until 
four  or  five  years  of  age.  Attention  must  be  given  such  children 
during  convalescence,  with  a  view  of  increasing  their  bodily 
resistance,  by  giving  proper  and  adequate  nourishment,  and 
securing  an  out-door  life. 

Diseased  Tonsils  Must  be  Removed. — We  should  watch  for 
and  correct  any  physical  abnormalities  that  may  be  present. 
Obstructions  to  breathing  particularly  demand  early  attention. 
Diseased  tonsils  and  adenoids  are  common  portals  of  entry  of 
the  tubercle  bacillus  in  infections  of  the  cervical  nodes.  Removal 
of  such  diseased  tissues  is  always  indicated  because  of  the  ob- 
struction to  breathing  and  dangers  of  infection,  and  is  very  fre- 
quently followed  by  subsidence  of  glandular  swellings,  but  there 
is  little  reason  to  believe  that  even  a  complete  removal  will  do 
more  than  slightly  aid  in  the  cure,  if  the  tubercle  bacilli  have 
passed  from  the  tonsils  or  adenoids  to  the  nodes.  A  tonsillectomy 
sometimes  immediately  accelerates  the  tuberculous  disease  in 
the  nodes.  Such  operation,  however,  is  an  adjuvant  to  direct 
treatment,  and  is  to  be  considered  in  every  case.  If  tonsils  are 
not  inflamed,  or  are  not  hypertrophic  and  obstructive,  it  is  wiser 
not  to  remove  them  for  no  indication  for  such  a  measure  then 
exists.  By  removing  healthy  tonsils  we  are  producing  an  in- 
terruption of  the  tonsillar  ring  of  Waldeyer,  and  may  we  not  in 
so  doing  lower  the  resistance  of  those  structures  to  the  advent 
of  infection? 

General  Treatment. — The  general  treatment  of  glandular 
tuberculosis  must  be  supportive  and  symptomatic.  Supportive 
treatment  relates  mainly  to  the  hygiene  of  living  and  to  the  diet. 
Ocean  and  mountain  climates  are  to  be  considered  and  when 
desirable  and  possible,  a  change  in  climate  is  indicated.  Fresh 
air  is  essential  and  whenever  possible  the  patient  should  be  in 
the  fresh  air  day  and  night.  A  proper  amount  of  rest  is  essential, 


152      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

even  when  there  is  no  fever  or  other  signs  of  toxaemia  present. 
When  the  temperature  goes  above  99.5°  F.  or  other  definite  toxic 
signs  present  themselves,  absolute  rest  is  imperative.  Patients 
that  are  about  should  take  a  definite  amount  of  rest  during  the 
day  and  plenty  of  sleep  at  night. 

Dietetic  Treatment. — Proper  dietetics  are  important  in  the 
treatment  of  any  form  of  tuberculosis,  under  the  influence  of 
which  the  subcutaneous  and  other  deposits  of  fat  disappear, 
and  the  muscles  decrease  in  size  and  in  tone.  To  counteract 
this  tendency  and  to  supply  energy  for  the  needs  of  the  body  in 
maintaining  its  equilibrium  and  combating  the  tuberculous 
disease,  food  of  proper  quantity  and  quality  is  essential.  All 
individuals  thrive  best  on  a  mixed  diet.  The  food  should  be 
nutritious  and  energy  producing  and  rather  rich  in  fats.  The 
amount  of  food  given  will  depend  upon  the  requirements  of  the 
individual  patient.  The  most  reliable  guide  to  a  patient's  con- 
dition is  his  gain  in  weight,  and  he  should  therefore  be  weighed 
weekly,  and  his  food  consumption  regulated  accordingly.  Not 
only  must  the  food  be  given  in  relative  abundance,  but  it  must 
possess  quality  and  variety  and  be  supplied  in  goodly  amount. 
Fat  is  essential  to  the  tuberculous  individual  in  maintaining  his 
nutrition  and  aiding  him  in  the  combat  with  his  disease.  That 
tuberculous  individuals  often  show  a  marked  aversion  for  fats 
is  a  common  observation.  Fat  is  best  supplied  in  the  form  of 
rich  milk,  cream  and  butter.  These  foods  are  quite  rich  in  fat 
and  are  easily  obtainable,  being  articles  of  ordinary  diet,  and 
palatable.  Fresh  pure  milk,  or  some  of  its  many  modifications 
are  of  great  value,  and  should  be  given  in  quantities  of  one  or 
two  quarts  daily.  Milk,  diluted  with  vichy  or  carbonated  water, 
can  be  tolerated  when  plain  milk  ofttimes  cannot. 

The  value  of  fat  in  the  treatment  of  tuberculosis  was  recog- 
nized in  the  use  of  cod  liver  oil.  Although  formerly  considered 
as  a  medicinal  agent,  and  its  therapeutic  value  attributed  to 
substances  such  as  iodides  contained  in  it  in  traces,  its  value 
must  be  conceded  to  be  due  to  its  fat  content,  and  it  may  properly 
be  classed  among  the  food  stuffs.  On  account  of  its  fatty  acid 
content  it  is  easily  digested  and  assimilated.  It  is  employed 


TREATMENT  153 

preferably  for  thin  excitable  children.  The  lighter  clear  refined 
oils  are  preferable,  being  milder  and  less  unpleasant  to  take. 
Many  children  will  take  the  oil  pure,  while  for  others  the  taste 
must  be  disguised.  It  may  be  given  in  the  form  of  an  emulsion, 
or  in  combination  with  malt.  It  should  be  given  after  meals  and 
given  over  a  long  period  of  time,  since  it  possesses  food  value  only. 
It  can  be  given  for  months  in  the  winter  time,  but  it  may  be 
necessary  to  interrupt  it  in  the  summer  or  at  any  time  if  it  causes 
digestive  disturbances,  such  as  eructations,  anorexia,  nausea, 
vomiting  or  diarrhoea.  Its  use  should  not  be  insisted  upon  if 
there  is  great  dislike  for  it. 

Many  foods  are  available.  In  nutritive  value  and  in  ease  of 
assimilation,  eggs  are  second  only  to  milk  and  are  subject  to  a 
variety  of  preparation.  Meats  should  be  given  in  moderation, 
and  the  more  robust  may  take  many  kinds  variously  prepared. 
Fried  meats  are  harder  to  digest.  Carbohydrate  food  is  avail- 
able in  many  forms.  Alcohol  is  contraindicated. 

Dangers  in  Overfeeding. — The  food  stuffs  prescribed  for  any 
patient  should  be  adapted  to  the  digestive  powers  and  tastes 
of  that  individual  patient.  Overfeeding  is  to  be  avoided  for  it  is 
harmful.  A  patient  is  overfed  when  he  takes  and  absorbs  more 
than  is  required  for  his  energy  exchanges.  The  important  point 
is,  not  what  a  tuberculous  patient  eats  but  what  he  can  digest 
and  assimilate.  An  excess  of  food  not  digested  and  absorbed 
is  likely  to  cause  alimentary  disturbances.  A  too  great  increase 
in  weight  due  to  the  deposition  of  fat  is  inadvisable,  for  fat  is 
relatively  inactive  and  an  excess  adds  little  to  one's  powers  of 
resistance. 

Tuberculin  Treatment. — The  use  of  tuberculin  in  treatment 
of  tuberculosis  was  first  introduced  by  Koch,  a  few  years  after 
his  discovery  of  the  tubercule  bacillus.  The  great  hopes  that 
were  placed  on  tuberculin  at  first  were  soon  shattered  The 
enormous  doses  administered,  instead  of  curing  the  disease, 
resulted  often  in  marked  aggravation  of  the  symptoms  and 
apparently,  in  many  cases,  hastened  the  end. 

Due  to  these  unfortunate  experiences,  tuberculin  came  into 
disfavor  amongst  the  medical  profession  at  large  and  would 


i54      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

certainly  have  lost  its  place  entirely  in  the  treatment  of  tuber- 
culosis, if  not  a  few  men  had  seen  the  real  cause  for  its  apparent 
failure. 

The  administration  of  large  doses  was  discontinued  by  these 
men  and  replaced  by  minute  doses.  Due  to  the  excellent  work 
done  by  these  investigators,  especially  in  Germany,  the  interest 
in  tuberculin  was  again  aroused  and  further  investigations  have 
fully  proven  to  men  of  unbiased  minds  that  tuberculin  has  a 
distinct  place  in  the  treatment  of  tuberculosis. 

No  Substitute  Offered  by  the  Men  who  Condemn  Tuberculin.— 
In  America  tuberculin  has  never  had  a  universal  use.  A  few 
men,  however,  have  clung  to  it  steadily  during  the  time  of  its 
evolution.  Tuberculin  has  often  been  condemned  by  the  pro- 
fession at  large.  But  a  change  in  opinion  is  bound  to  come,  the 
work  of  many  men  in  our  country,  giving  absolute  proof  of  the 
value  of  tuberculin,  will  without  question,  in  due  time,  get  the 
recognition  it  deserves. 

Tuberculin  of  to-day  is  not  the  last  word  in  treatment  of  tuber- 
culosis; far  be  it  from  me  to  assume  it.  But  of  all  the  remedies 
that  have  been  projected  tuberculin,  in  my  opinion,  stands  so 
much  in  advance  of  any  other  single  agent  that  it  cannot  be 
thrown  aside  by  the  conscientious  practitioner. 

Varieties  of  Tuberculin. — A  large  number  of  tuberculins  have 
been  discovered  both  for  diagnostic  and  therapeautic  purposes, 
Many  of  our  foremost  authors  on  the  subject  of  tuberculosis, 
notably  WOLFF-EISNER  and  SAHLI,  consider  that  the  active 
principle  in  all  the  tuberculins  is  very  much  the  same,  being  a 
tuberculo-protein.  This  is,  according  to  SAHLi,3  proven  by  the 
exactly  similar  character  of  the  so-called  tuberculin  reactions 
which  can  be  produced  by  all  tuberculins  without  exception. 
But  we  know  that  variations  as  to  degree  of  reaction  are  man- 
ifested by  the  various  preparations.  This  is  undoubtedly  due 
to  the  differences  in  the  constituent  portions  of  the  various 
tuberculin-proteins,  fats  and  toxins  being  present  in  different 
amounts  and  different  degrees  of  availability.4 

Koch's  Old  Tuberculin. — The  original  article  discovered  by 
KOCH  and  called  "Koch's  Old  Tuberculin,"  has  served  as  a 


TREATMENT  i55 

basis  for  nearly  all  new  varieties  and  is  considered  by  many  as 
the  tuberculin  par  excellence.  It  is  made  by  growing  a  culture 
in  a  glycerinated  (5%)  alkaline  broth  for  six  to  eight  weeks, 
which  is  then  sterilized  and  concentrated  to  one-tenth  of  its 
original  volume  and  finally  filtered  through  a  Berkefeld  filter. 
Old  tuberculin,  therefore,  is  a  glycerinated  extract  of  the  bacil- 
lary  bodies,  containing  also  the  products  which  were  formed 
during  their  growth,  and  also  some  extraneous  material  from  the 
culture  medium.  The  peptone  contents  of  the  latter,  although 
very  minute  in  quantity,  caused  Koch  to  manufacture  his  al- 
bumose-free  tuberculin,  which  is  identical  with  the  old  with  the 
exception  that  it  is  grown  on  asparagin  culture  medium  and 
hence  does  not  contain  any  peptone  bodies. 

Other  varieties  are  Koch's  new  tuberculin  (T.  R.)  which  at 
present  is  hardly  used  at  all.  Koch's  bacillary  emulsion,  by  many 
considered  the  most  valuable  of  all  tuberculins,  scarcely  contains 
anything  else  than  the  most  finely  powdered  body-substance  of 
the  tubercle  bacilli.  The  sensitized  bacillary  emulsion  of  MEYERS, 
which,  in  addition  to  bacillary  bodies,  also  contains  tuberculous 
serum.  BEEANECK'S  tuberculin,  strongly  recommended  by 
SAHLI,  is  grown  on  peptone-free  culture  media  and  is  essentially 
a  mixture  of  tubercle  broth,  filtered  free  from  bacilli  and  evap- 
orated down  to  vacuo  at  a  low  temperature,  with  an  extract  of 
the  bodies  of  tubercle  bacilli  made  with  orthophosphoric  acid. 
This  latter,  therefore,  contains  the  bacillary  protein  in  the  form 
of  an  acid  orthophosphate  of  albumin. 

Constituents  of  Tuberculin. — The  more  recent  investigations, 
into  the  question  of  tuberculin,  show  a  distinct  tendency  to  sepa- 
rate the  bacillary  bodies  into  their  simpler  compounds,  proteins, 
fats,  etc.  VAUGHN  has  separated  one  soluble  and  one  insoluble 
protein;  DEYCKE  and  MUCH  have  produced  various  partial 
antigens  belonging  to  the  protein,  fat  and  toxin  groups;  v. 
RUCK  has  isolated  several  proteins.  POTTENGER  5  is  undoubtedly 
right  in  assuming  that  the  work  of  these  men  is  pointing  the  way 
to  future  improvements  in  the  production  of  specific  tubercle 
vaccines. 

Action  of  Tuberculin. — The  specific  action  of  tuberculin  is  that 


156      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

of  active  immunization,  hence  a  few  words  about  the  subject 
of  immunity  with  regard  to  tuberculosis  are  not  amiss. 

Immunity  to  tuberculosis  is  a  very  much  disputed  question 
at  the  present  time.  The  opinions  vary  from  one  extreme  to 
the  other.  Some  observers  do  not  believe  that  any  immunity 
exists  whatsoever  against  this  dreadful  disease.  Others  believe 
that  it  is  immunity  which  plays  the  foremost  role  in  saving  the 
human  race  from  complete  extinction. 

Natural  immunity  is  the  resistance  to  infection,  normally 
possessed,  usually  as  the  result  of  inheritance,  by  certain  in- 
dividuals or  species  under  natural  conditions.  The  existence  of 
this  form  of  immunity  is  very  hard  to  prove.  REIBMAYR  6  be- 
lieves that  he  has  proved  it  for  single  families  who,  in  the  struggle 
for  life,  have  acquired  and  handed  down  from  generation  to  gen- 
eration a  resistance  to  tuberculosis  by  having  recovered  from  the 
disease. 

An  apparent  support  of  this  is  the  severe  nature  of  the  disease 
when  it  attacks  races  of  people  who  have  not  before  been  in 
contact  with  tuberculosis.  For  instance,  the  negroes  in  Africa 
are  very  susceptible  to  the  disease  and  the  fatality  is  enormous. 
The  American  Indian  fell  an  easy  prey  to  the  White  Man's 
Great  White  Plague;  more  recently  has  DEYCKE  7  reported  the 
condition  amongst  Turks  who,  it  appears,  have  not  come  into 
contact  with  tuberculosis  to  a  marked  extent  until  recently. 
Amongst  them  the  disease  shows  itself  in  a  very  acute  and  severe 
form  and  has  a  malignant  course. 

The  contention  then  seems  reasonable  that  amongst  those 
living  in  contact  with  tuberculosis  there  must  be  a  very  real, 
if  only  a  relative  immunity.  To  express  it  in  BULLOCK'S  words  8 — 
"Physicians  or  no  physicians,  science  or  no  science,  nature  is 
quietly,  but  none  the  less  persistently  and  effectively,  immunizing 
the  human  race  against  tuberculosis."  An  analogy  may  here  be 
seen  with  what  has  occurred  in  lues  and  leprosy. 

But  the  question  has  arisen  if  this  severe  form  of  tuberculosis 
attacking  new  races  is  not  caused  by  the  absence  of  the  pro- 
tective influence  of  a  mild  infection  during  childhood. 

The  question  of  ACQUIRED  IMMUNITY  thus  arises.    It  has  often 


TREATMENT  157 

been  said  that  the  difference  in  reaction  to  tuberculosis  in  chil- 
dren and  adults  is  due  to  the  difference  in  age.  In  view  of  the 
recent  investigations  this  supposition  does  not  seem  to  hold  true. 
The  individual  reacts  in  one  way  to  the  original  infection,  may 
it  occur  in  childhood  or  adult  life;  in  another  way  to  super  or 
reinfection.  Hence,  the  similarity  between  the  disease  of  child- 
hood, when  a  severe  infection  is  present,  and  that  of  adults  in  a 
race  recently  exposed  to  the  disease. 

KOCH'S  phenomenon,  without  question,  constitutes  the  most 
important  research  in  immunity  to  tuberculosis.  His  experiments 
are  so  classical  and  their  importance  so  great  that  a  detailed 
description  is  not  malplaced  .9 

"  When  one  vaccinates  a  healthy  guinea-pig  with  a  pure  culture  of 
tubercle  bacilli,  the  wound,  as  a  rule,  closes  and  in  the  first  few  days 
seems  to  heal.  However,  in  from  ten  to  fourteen  days  a  hard  nodule 
appears  which  soon  breaks  down,  leaving  an  ulcer  that  persists  to  the 
time  of  death  of  the  animal.  There  is  quite  a  different  sequence  of 
events  when  a  tuberculous  guinea-pig  is  vaccinated;  for  this,  animals 
are  best  suited  that  have  been  successfully  infected  for  four  to  six  weeks 
previously.  In  such  an  animal  the  inoculation  would  also  promptly 
unite.  However,  no  nodule  forms,  but  on  the  next  or  second  day  after 
a  peculiar  change  occurs.  The  point  of  inoculation  and  the  tissues 
about,  over  an  area  of  o.  I  to  i  c.m.  in  diameter  grow  hard  and  take  on 
a  dark  discoloration.  Observation  on  subsequent  days  makes  it  more 
and  more  apparent  that  the  altered  skin  is  necrotic.  It  is  finally  cast 
off  and  a  shallow  ulceration  remains  which  usually  heals  quickly  and 
permanently  without  the  neighbouring  lymph-glands  becoming  in- 
fected. Inoculated  tubercle  bacilli  act  very  differently  upon  the 
skin  of  healthy  and  tuberculous  guinea-pigs.  This  striking  action  is 
not  restricted  to  living  tubercle  bacilli,  but  is  equally  manifested  by 
dead  bacilli  whether  they  be  killed  by  exposure  to  low  temperature, 
for  a  long  time,  or  to  the  boiling  temperature,  or  by  the  action  of  va- 
rious chemicals. 

"  After  having  discovered  these  remarkable  facts  I  followed  them  up 
in  all  directions  and  was  further  able  to  show  that  killed  pure  cultures 
of  tubercle  bacilli,  ground  up  and  suspended  in  water,  can  be  injected 
in  large  amounts  under  the  skin  of  healthy  guinea-pigs  without  pro- 
ducing any  other  effect  than  local  suppuration.  Tuberculous  guinea- 


158      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

pigs,  on  the  other  hand,  are  killed  in  from  six  to  forty-eight  hours, 
according  to  the  dose  given,  by  the  injection  of  small  quantities  of 
such  suspension.  A  dose  which  just  falls  short  of  the  amount  nec- 
essary to  kill  the  animal  may  produce  extensive  necrosis  of  the  skin 
about  the  point  of  injection.  If  the  suspension  be  diluted  until  it  is 
just  visibly  cloudy,  the  injected  animals  remain  alive,  and  if  the  ad- 
ministration is  continued  with  one  or  two  intervals,  a  rapid  improve- 
ment in  their  condition  takes  place;  the  ulcerating  inoculation  wound 
becomes  smaller,  and  is  finally  replaced  by  a  scar,  a  process  that  never 
takes  place  without  such  treatment;  the  swollen  lymph-glands  become 
smaller,  the  nutrition  improves  and  the  disease  process,  unless  it  is 
too  far  advanced  and  the  animals  die  of  exhaustion,  comes  to  a  stand- 
still." 

ROMER,  one  of  our  foremost  students  on  immunity  in  tuber- 
culosis, has  substantiated  the  findings  of  KOCH  and  has  also, 
in  a  most  striking  manner,  proved  that  protective  vaccination 
is  possible  in  cattle  and  sheep.  He  vaccinated  cattle  with 
living  tubercle  bacilli  of  a  human  strain,  non-lethal  for  cattle.10 
When  these  animals  were  later  subjected  to  the  inoculation  of 
a  large  dose  of  virulent  tubercle  bacilli  they  showed  an  immediate 
reaction  of  rise  in  temperature.  But  this  gradually  subsided  and 
a  complete  cure  resulted.  The  controls  of  non- vaccinated  an- 
imals, however,  reacted  in  the  usual  manner  and  soon  died  from 
typical  inoculation  tuberculosis.  ROMER  vaccinated  sheep  in  the 
same  manner,  using  bovine  tubercle  bacilli.11  Sheep,  according 
to  this  investigator,  approach  men  in  their  resistance  to  tuber- 
culous infection.  A  sheep  infected  subcutaneously  August  6, 
1908,  with  virulent  bovine  tubercle  bacilli,  and  reinfected  intra- 
venously with  more  than  double  the  number  of  the  same  bacilli 
on  March  3,  1909,  when  killed  September  i,  1909,  showed  but 
trifling  tuberculous  changes,  those  that  were  present  being  sim- 
ilar to  and  not  of  greater  extent  than  those  found  in  a  control 
animal  which  had  received  the  first,  but  not  the  second  injection, 
while  the  control  of  the  second  injection  died  in  two  months  with 
enormous  tuberculosis  of  the  lungs. 

In  his  experiments  on  guinea-pigs,  ROMER  showed  that  the 
immunity  enjoyed  after  reinfection  was  not  due  to  the  fact  that 
the  tubercle  bacilli  had  all  been  destroyed,  for  a  bit  of  apparently 


TREATMENT  iS9 

unaltered  skin  over  the  site  of  reinfection  in  the  tuberculous 
guinea-pig  being  cut  out  and  injected  in  a  free  guinea-pig  caused 
the  death  of  the  animal  from  typical  inoculation  tuberculosis. 

Bearing  these  investigations  in  mind,  when  considering  the 
question  of  tuberculosis  in  men,  some  conclusions  seem  justified. 
BULLOCK  12  remarks  that  the  lifelong  and  very  practical  immunity 
possessed  by  the  six-sevenths  of  the  human  family  must  be  largely 
the  result  of  a  primary  and  insignificant  infection  with  its  result- 
ing sensitization,  or,  as  might  be  said,  state  of  preparedness. 

If  we  consider  the  enormous  number  of  adults  who  react  to 
tuberculin,  without  having  any  clinical  manifestations  of  tuber- 
culosis whatsoever,  we  must  conclude  that  a  positive  v.  Pirquet 
tuberculin  reaction  is  not  a  sign  of  active  disease,  but  only  shows 
that  the  individual  has  had  a  tuberculous  infection.  Hence, 
all  cases  of  tuberculosis  are  not  progressive;  some  cases  may  be 
cured,  and  some  have,  as  MUCH  13  says,  acquired  a  certain  degree 
of  immunity,  overcoming  the  initial  infection  as  is  shown  by  the 
presence  of  a  large  amount  of  immune  bodies.  MUCH  further 
argues  that  the  constant  exposure  of  man  to  tuberculosis,  with- 
out question,  causes  repeated  infections  but  that  the  individual, 
by  virtue  of  his  acquired  immunity,  easily  conquers  them.  On 
account  of  these  repeated  attacks  are  the  body  defenses  strength- 
ened, and  the  immune  bodies  increased  in  number.  This  may 
give  an  explanation  for  the  presence  of  antibodies  in  the  individ- 
ual, years  after  the  initial  infection  in  childhood. 

In  view  of  these  arguments  the  truth  in  LOWENSTEIN'S  am- 
biguous statement  is  clearly  seen— "Only  the  tuberculous  are 
tuberculosis  immune."  The  calcified  bronchial  glands  have 
been  called  the  vaccination  mark  of  tuberculosis.  In  truth,  a 
proper  name.  But  for  this  protection,  acquired  of  course  at 
great  risk  to  the  child,  it  is  presumed  by  some  that  adult  human 
beings  would  be  as  susceptible  to  first  infections  as  adults  of 
other  animals  are  known  to  be.  As  F.  C.  SMITH  14  says,  "the 
immunity  of  adults  is,  therefore,  no  great  cause  for  congratula- 
tion; it  is  attained  at  too  great  a  price." 

Theories  of  Reaction  to  Tuberculin.— Healthy  animals  do  not 
react  to  tuberculin  when  the  latter  is  injected  in  moderate  doses. 


160      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

In  tuberculous  animals,  on  the  other  hand,  the  injection  of  the 
most  minute  amounts  cause  a  profound  change  in  the  body- 
equilibrium;  the  temperature  is  raised,  signs  of  marked  activity 
appear  at  the  seat  of  disease  and  some  changes  at  the  site  of 
administration  of  the  tuberculin.  The  manifestations  of  the 
reaction  have  been  fully  discussed  in  the  chapter  on  Tuberculin 
Diagnosis. 

Many  theories  have  been  proposed  to  explain  the  phenomena 
of  tuberculin  reactions.  The  first  suggestion  was  that  tuberculin 
acts  so  powerfully  in  an  infected  individual  by  reason  of  the  fact 
that  a  certain  amount  of  it  is  present  in  the  organism,  having 
been  formed  in  the  tuberculous  focus.  The  addition  of  injected 
tuberculin  to  that  already  present  in  the  circulation  causes  the 
general  reaction,  and  its  addition  to  that  in  the  focus  causes  the 
focal  reaction.  This  summation  theory,  in  many  respects,  fails 
to  offer  a  complete  or  satisfactory  explanation  and  may,  therefore, 
be  discarded. 

Wasserman  and  Bruck's  Theory. — A  more  recent  theory  is 
that  of  WASSERMAN  and  BRUCK.15  Following  the  success  of  the 
complement  deviation  reaction  in  the  diagnosis  and  control  of 
treatment  in  syphilis  they  applied  the  reaction  to  the  study  of 
serum  of  tuberculous  individuals.  They  found  an  immune  body, 
or  amboceptor,  which  they  term  "anti- tuberculin"  and  which, 
with  tuberculin,  binds  complement.  Upon  this  basis  they  at- 
tempted to  explain  the  tuberculin  reactions,  believing  the  com- 
plement fixation  to  be  the  cause.  They  conclude  that  a  focal  reac- 
tion occurs  after  the  injection  of  tuberculin,  the  antituberculin 
meeting  the  antigen  tuberculin  and  fixing  complement  in  the 
tuberculous  focus.  This  causes  the  softening  of  the  tissues  of 
the  focus  and  the  focal  reaction,  the  protein  digesting  power 
being  attributed  to  the  fixed  complement.  The  general  and 
febrile  reactions  are  due  to  the  absorption  of  products  from  the 
softened  tubercular  tissue.  The  general  reaction  is  thus  made 
secondary  to  the  focal  reaction.  The  theory  has  not  given  an 
entirely  satisfactory  explanation  of  the  tuberculin  reaction,  but 
has  excited  interest  and  stimulated  research  work  in  complement 
deviation  in  tuberculosis. 


TREATMENT  !6i 

Sahli's  Objection.— SAHLI  16  calls  attention  to  objections  to 
the  theory.  He  considers  it  "quite  incomprehensible  how  tuber- 
culin and  antituberculin  can  exist  simultaneously  in  tuber- 
culous foci  without  neutralizing  one  another  under  the  influence 
of  complement  which  is  always  present."  He  also  finds  the  ex- 
planation of  inflammatory  reactions  unsatisfactory  since  the 
chemical  affinities  are  satisfied,  and  considers  that  the  action  of 
complement  would  be  directed  to  the  combination  of  tuberculin 
and  antituberculin  rather  than  to  digestion  of  the  tissues. 

v.  Pirquet  and  Schick's  Views. — v.  PIROUET  17  observed  that 
an  organism  which  has  gone  through  an  infection  changes  its 
power  of  reaction  to  the  same  causative  agent;  this  change,  the 
so-called  allergic  reaction,  is  seen  most  clearly  when  an  extract 
of  the  infective  agent  is  inoculated  into  the  skin.  He  and  SCHICK 
held  that  the  tuberculin  reaction  is  due  to  the  formation  of  toxic 
substances  as  a  result  of  the  combination  of  antibodies  and  the 
injected  tuberculin.  This  formation  of  toxin  may  occur  locally 
and  in  the  blood-stream  as  well,  thus  accounting  for  both  the 
local  and  general  reactions. 

Wolff-Eisner's  Theory. — WOLFF-EISNER  18  has  modified  the 
theory  of  WASSERMAN  and  BRUCK.  He  observed  that  "the  first 
injection  of  a  foreign  albuminous  substance  produces  no  immu- 
nity but  always  hypersensitiveness  which  is  evident  on  the  second 
injection  of  the  same  albuminous  substance."  He  believes  in 
the  existence  in  tuberculosis  of  an  antibody  of  the  nature  of  an 
amboceptor,  which  according  to  him,  is  lytic  in  character.  He 
concludes  that  specific  lysins  are  elaborated  by  the  organism, 
which  are  able  to  break  up  complex  molecular  aggregates,  setting 
free  from  the  foreign  proteins  by  this  lytic  action,  endotoxin-like 
substances  which  exhibit  an  increased  toxic  action.  He  assumes 
that  the  active  principle  in  the  tuberculin  consists  of  ultra- 
microscopic  fragments  of  the  bacteria,  hence  a  foreign  albu- 
minous material  which  is  of  comparatively  low  toxicity  as  ev- 
idenced by  the  large  doses  tolerated  by  those  who  are  free  from 
tuberculous  infection.  The  sensitive  tuberculous  person  has 
this  specific  lysin  in  his  body  as  the  result  of  his  infection,  and 
the  antibody,  the  bacteriolytic  amboceptor,  under  the  action  of 


162      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

complement  unlocks,  so  to  speak,  or  splits  the  tuberculo-protein 
into  secondary  products,  less  complex  molecules  of  high  toxicity, 
which  have  an  irritative  action  on  the  tuberculous  foci,  thus  pro- 
ducing the  focal  reaction.  The  general  reaction  occurring 
simultaneously  is  due  to  the  action  of  these  same  toxins  on  the 
system  in  general.  This  presupposes  then  that  the  tuberculin 
which  has  become  lysinized  and  being,  therefore,  toxic  is  neutral- 
ized by  the  protective  reaction  of  the  organism  by  the  formation 
of  antitoxic  antibodies. 

Theory  of  Anaphylaxis. — The  modern  tendency  is  to  consider 
the  tuberculin  reaction  as  an  allergic  or  anaphylactic  reaction 
phenomenon.  Early  observations  of  anaphylactic  reactions  were 
made  by  PORTRER,  ARTHUS,  THEOBALD  SMITH  and  others  when 
they  demonstrated  that  sensitization  to  serums  and  toxins  was 
manifested  by  a  severe  reaction  when  a  second  injection  was  given 
after  an  interval  of  several  days  had  elapsed.  Such  substances 
have  received  the  name  of  anaphylactogens  since  they  produce 
a  specific  hypersusceptibility  after  an  incubation  period  of  at 
least  five  to  seven  days. 

Anaphylactogens  are  proteins  or  are  inseparably  connected  with 
proteins.  The  parenteral  introduction  of  an  anaphylactogen  leads 
to  the  production  of  a  specific  antibody  termed  anaphylactin. 
Several  days  are  required  for  the  production  of  this  antibody, 
or  immune  substance,  thus  accounting  for  the  incubation  period. 
The  subsequent  injection  of  anaphylactogen  leads  to  the  reaction. 
VAUGHN  and  others  consider  that  the  process  of  sensitization 
consists  in  the  development  of  specific  proteolytic  ferments,  and 
the  reaction  to  enzymatic  proteolysis  by  means  of  which  the 
foreign  protein  is  broken  up  into  toxic  substances. 

Vaughn's  Theory. — VAUGHN  19  has  shown  that  proteins  can 
be  hydralized  with  alcohol  and  sodium  hydrate  into  one  portion 
with  highly  toxic  action  and  another  portion  which  showed 
marked  sensitizing  property  but  little  toxicity.  These  principles 
of  anaphylaxis  can  easily  be  applied  to  the  explanation  of  the 
tuberculin  reaction.  The  tuberculin  formed  in  the  tuberculous 
focus  leads  to  the  production  of  specific  proteolytic  ferments 
and  the  organism  is  thus  sensitized.  When  tuberculin  is  intro- 


TREATMENT 


163 


duced  from  without  the  ferments  act  upon  it  and  liberate  the 
toxic  element;  the  reactions  result  from  its  irritant  action  upon 
the  body  cells.  The  similarity  of  this  theory  and  WOLFF-EISNER'S 
is  readily  seen;  he  speaks  of  a  lytic  amboceptor,  and  VAUGHN, 
and  others,  adherents  of  the  anaphylaxis  theory,  of  proteolytic 
ferment. 

While  the  fundamental  hypothesis  of  the  theory  of  parenteral 
digestion,  as  developed  by  VAUGHN  and  others,  has  been  gen- 
erally accepted,  there  is  some  difference  of  opinion  as  to  the  mech- 
anism by  which  it  is  formed  in  the  body.  According  to  the  early 
assumption,  it  is  entirely  an  intra-vascular  affair;  this  is  sub- 
stantiated by  the  experiments  of  BIEDL  and  KRAUS,  FRIEDEMANN 
and  others,20  which  shows  that  all  the  factors  necessary  for  the 
production  of  allergic  reactions  may  be  present  in  the  blood- 
stream. Recent  researches,  however,  seem  to  place  marked  im- 
portance upon  cellular  reactivity.  PEARCE  and  EISENBERG  21 
using  transfusion  methods,  SCHULTZ,  DALE  and  WEIL22  using 
isolated  muscle  tissue  of  sensitized  animals,  have  shown  con- 
clusively that  the  conditions  of  hypersensitiveness  is  largely  deter- 
mined by  an  increased  capacity  for  reaction  on  the  part  of  the 
fixed  cells  to  the  specific  antigen,  probably  occasioned  by  an 
excess  of  specific  antibodies  or  enzymes  in  the  protoplasm. 

General  Action. — Tuberculin  treatment  consists  essentially 
of  an  immunizing  healing  action  which  is  not,  however,  a  com- 
plete immunization  but  only  a  relative  one.  This  relative  immu- 
nity presupposes  an  increase  in  the  capacity  for  resistance  by 
the  stimulation  of  all  the  anatomical  and  physiological  processes 
which  are  so  frequently  causative  in  the  spontaneous  healing 
of  tuberculous  lesions. 

The  process  of  immunization  consists  of  raising  the  natural 
capacity  present  in  the  organism  of  reacting  to  the  tuberculous 
toxin.  In  tuberculin  immunization  the  body  primarily  tolerates 
increasing  quantities  of  tuberculin,  but  also  renders  inocuous 
the  toxins  elaborated  in  the  tuberculous  foci. 

Whether  or  not  the  tuberculin  contains  the  real  toxin  of  tubercle 
bacilli  is  still  not  determined.  Those  who  have  assumed  the 
negative,  base  their  opinion  largely  upon  the  fact  that  complete 


1 64      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

immunization  to  tuberculosis  by  means  of  tuberculin  cannot  be 
obtained.  The  production  of  tubercles  by  tuberculin  apparently 
leaves  but  little  doubt  that  the  same  toxin  is  found  both  in  tuber- 
culin and  tubercle  bacilli.  SAHLI  basing  his  opinion  upon  the 
lysin  theory,  concludes  that  the  difference  in  action  between  the 
tubercle  bacilli  and  tuberculin  is  merely  one  of  degree. 

The  v.  RUCKS  are  of  the  opinion  that  actively  acquired 
immunity  against  bacillus  tuberculosis  is  not  produced  against 
its  secretions  and  body  constituents  simultaneously.  They 
maintain  that  this  immunity  is  established  gradually.  First, 
against  the  toxins  elaborated  by  the  living  tubercle  bacilli,  and 
later  against  the  constituents  of  the  bacillus  in  direct  proportion 
to  their  solubility  and  rapidity  of  destruction  of  the  bacillus. 
This  is  necessarily  slow  because  the  bacillus  is  resistent  to  sol- 
vents and  also  are  enclosed  in  non-vascular  tubercles. 

The  specific  actions  of  the  substances  which  are  concerned  in 
production  of  immunity,  such  as  antitoxins,  agglutinins,  precip- 
itins,  aggressins,  opsosins,  etc.,  can  be  studied  in  modern  works 
on  immunity. 

Local  Action. — The  local  action  of  tuberculin  upon  the 
focus  of  infection  is  one  of  the  greatest  importance,  and  is  un- 
doubtedly dependent  upon  the  inflammatory  hyperemia  pro- 
duced. This  increases  the  phagocytic  activity  of  the  leuco- 
cytes which,  though  present  in  the  natural  course  of  tuberculosis, 
are  increased  by  tuberculin  treatment.  Through  this  local 
hyperemia  actual  healing  of  lesion  is  produced  with  absorption 
of  the  diseased  tissue  and  formation  of  new  connective  tissue. 

Indications  for  the  Use  of  Tuberculin. — The  use  of  tuberculin 
in  treatment  of  tuberculosis  of  the  lymphatic  system  has,  in  my 
experience,  produced  very  fortunate  results. 

Tuberculous  adenitis  in  any  stage  lends  itself  with  great  hope 
of  success  to  the  treatment  with  tuberculin;  cases  with  suppur- 
ating glands  are  markedly  improved  and  often  subside  without 
any  surgical  interference  whatever.  In  some  cases  simple 
aspiration  of  glandular  abscess  seems  necessary  before  healing 
can  take  place.  Old  cases  of  tuberculous  adenitis  with  chronic 
discharging  sinuses,  which  have  been  operated  on  time  and  time 


TREATMENT  165 

again  without  any  apparent  result,  often  yield  to  a  long  con- 
tinued tuberculin  treatment. 

Contraindications  to  tuberculin,  as  it  is  administered  at  the 
present  time,  are  few  indeed.  Advanced  Bright's  disease,  de- 
compensated  heart  lesions,  pregnancy,  acute  infections,  diabetes, 
and  markedly  advanced  cases  of  pulmonary  tuberculosis. 

Method  of  Administrations. — In  the  discussion  of  the  specific 
diagnosis  of  tuberculosis,  I  presented  my  views  in  regard  to  the 
dosage  of  tuberculin  in  the  subcutaneous  test,  and  emphasized 
that  only  comparatively  small  amounts  of  tuberculin  were 
necessary  to  excite  a  reaction.  The  importance  of  this  is  par- 
amount. The  reaction  to  tuberculin,  when  it  occurs,  is  an  un- 
controllable factor  and  may  undoubtedly,  in  some  cases,  lead  to 
unfavorable  results — hence,  the  importance  to  select  your  cases. 

Our  strife  in  treatment  of  tuberculosis  is  to  carry  on  the  same 
without  exciting  any  apparent  reaction.  In  cases  of  glandular 
tuberculosis  the  danger  is  less  than  in  pulmonary  tuberculosis 
but  should,  however,  be  kept  in  mind.  A  reaction  may  indeed 
be  of  value  in  some  cases  and  hasten  recovery,  acting  as  a  marked 
stimulus  to  production  of  antibodies. 

One  should  always  remember,  as  BANDELIER  and  ROEPKE  23 
have  stated,  that  tuberculin  does  not  contain  any  readymade 
healing  factors,  but  they  are  produced  by  the  organism  itself 
as  an  anti-action  against  the  poison. 

The  smallest  dose  of  tuberculin  undoubtedly  is  accompanied 
by  some  reactive  changes,  both  generally  and  locally.  The  dose 
to  do  the  most  good  would  be  one  that  produced  the  greatest 
amount  of  focal  reaction  without  eliciting  a  general  reaction, 
the  latter  as  manifested  by  rise  in  temperature  and  other  signs 
of  toxic  surcharge. 

The  irritative  action  upon  the  focal  lesion  produces  tissue  dam- 
age, associated  with  hyperaemia,  and  is  the  important  factor  in 
recovery,  as  long  as  it  does  not  exceed  the  optimum  amount 
of  damage.  When  tissue  damage  is  excessive,  the  progress  of 
the  disease  is  facilitated  with  the  occurrence  of  favor  and  exten- 
sion of  inflammation  in  the  tuberculous  foci. 

Toxic  Phenomena,  Indicative  of  a  Reaction.    The  typical  reac- 


i66      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

tions  to  a  diagnostic  dose  of  tuberculin  have  been  discussed  under 
the  subject  of  specific  diagnosis  and  should  always  be  avoided 
during  the  progress  of  treatment.  More  subtle  findings,  however, 
make  their  appearance  when  we  are  nearing  the  zone  of  danger. 
During  the  progress  of  tuberculin  treatment  the  patient  should 
show  a  distinct  general  improvement.  The  first  signs  to  appear 
in  case  patient  is  not  reacting  properly  are  often  overlooked. 
They  may  apparently  be  so  insignificant  as  to  be  considered  of 
no  value,  but  the  physician  should  always  be  on  the  lookout. 
The  patient  may  begin  to  show  symptoms  of  a  general  indisposi- 
tion, become  irritable,  lose  his  appetite  and  consequently  lose 
weight.  The  latter  is  by  many  considered  one  of  the  most 
valuable  signs  of  trouble  ahead.  It  is  often  the  only  finding, 
indicative  of  lack  of  response.  Hence,  the  marked  importance 
of  weighing  the  patients  at  regular  intervals  to  ascertain  the 
proper  facts. 

Acceleration  of  the  pulse  is  emphasized  by  some  authors  as  a 
very  important  factor  as  indicative  of  untoward  reaction.  The 
temperature,  of  course,  plays  an  important  role  and  is  often  the 
only  means  whereby  some  clinicians  control  their  doses.  The 
slightest  rise  in  temperature  should  be  looked  at  askance  as  a 
possible  forerunner  of  a  marked  reaction.  The  slightest  rise 
should  have  subsided  before  the  next  injection  is  given. 

If  any  of  the  above  signs  of  hypersensitiveness  do  appear, 
the  increase  in  dosage  should  be  very  gradual  indeed .  Oftentimes 
it  is  imperative  to  repeat  the  same  dose  several  times  before 
toximmunity  for  that  particular  dose  is  reached.  In  some  cases 
we  find  signs  of  accumulative  action  with  a  typical  reaction  follow- 
ing the  repetition  of  the  same  dose.  In  these  cases  treatment 
must  be  suspended  for  one  to  two  weeks,  and  the  next  injection 
must  not  be  increased ,  and  the  subsequent  increase  in  dosage  must 
be  undertaken  very  carefully. 

The  way  to  administer  tuberculin  is  by  subcutaneous  injection. 
Other  methods  have  been  tried;  orally,  rectally  by  suppositories, 
etc.,  but  their  failure  has  been  demonstrated. 

The  site  of  injection  varies  with  different  men.  Some  prefer 
the  back,  others  the  tissues  of  anterior  aspect  of  the  chest.  Per- 


TREATMENT 


167 


sonally,  I  nearly  always  use  the  tissues  of  the  arm.  This  area 
undoubtedly  is  somewhat  more  sensitive  to  local  reaction  than 
the  others,  and  sometimes  a  local  reaction  may  occur  which,  if 
of  small  volume,  may  be  disregarded.  This  local  affair  undoubt- 
edly is  caused  by  the  trace  of  tuberculin  left  in  the  skin  during 
introduction  of  the  needle,  and  hence  may  be  regarded  as  a  mod- 
ified v.  Pirquet  reaction. 

Time  for  Injection. — Tuberculin  is  usually  administered  in 
the  morning  when  practicable.  The  reason  for  this  is  manifest. 
A  reaction  to  tuberculin  often  occurs  with  4-6  hours  and  in  such 
a  case  a  possible  rise  in  temperature  would  be  noted,  whereas  if 
administered  in  the  afternoon  or  evening  it  would  be  overlooked 
during  sleeping  hours.  Another  reason  is,  that  the  usual  after- 
noon rise  of  temperature  is  followed  by  the  customary  fall  the 
following  morning.  If  tuberculin  is  injected  in  the  afternoon  a 
febrile  reaction,  which  may  occur  the  following  morning,  may  be 
obscured  by  the  morning  drop  in  temperature. 

Dosage  an  Individual  Question. — Tuberculin  does  not  truly 
immunize  the  organism,  but  merely  strives  at  increasing  the 
capacity  of  the  organism  for  anti-action.  As  this  capacity  for 
anti-action  is  different  in  each  patient,  the  dosage  varies  accord- 
ingly and  hence  resolves  itself  into  a  study  of  each  individual. 
The  strength  of  the  initial  dose  varies  with  the  age  of  the  patient, 
the  presence  or  not  of  fever,  of  marked  hypersensitiveness,  etc. 
The  initial  dose  should  be  repeated  several  times  to  demonstrate 
the  presence  or  not  of  any  cumulative  action.  If  signs  of  this 
appear,  the  next  dose  should  be  withheld  until  they  disappear. 

The  individuality  of  the  treatment  should  never  be  lost  sight 
of.  We  are  dealing  with  a  powerful  therapeutic  agent  which  has 
to  be  handled  very  carefully  if  we  want  to  get  the  best  results. 
The  physician  should  always  be  on  the  lookout  for  signs  of  pos- 
sible toxic  reaction,  the  reactionless  treatment  being  the  ideal 
to  obtain.  The  slightest  toxic  irritation  signs  absolutely  indicate 
a  prolongation  of  the  intervals  between  injections. 

In  the  treatment  of  glandular  tuberculosis  I  use  very  small 
doses  throughout  the  entire  course  of  treatment — smaller  than 
in  pulmonary  tuberculosis.  This  with  clear  understanding  of 


168      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

the  fact  that  the  focal  response  to  tuberculin  is  less  marked  than 
in  any  other  tuberculous  lesion.  As  we  have  pointed  out  before, 
the  main  factor  in  producing  healing  at  the  site  of  lesion  is  the 
new  connective  tissue  formation.  This  is  markedly  stimulated 
during  tuberculin  treatment.  The  peculiar  structure  of  the 
gland  favors  this  formation.  A  too  rapid  stimulation  by  tuber- 
culin would  cause  an  undue  formation  of  fibroid  tissue,  leaving 
the  glands  enlarged  in  spite  of  the  actual  healing  of  the  tuber- 
culous lesions.  This  has  apparently  quite  an  important  bearing 
upon  the  question  of  treating  tuberculous  cervical  adenitis, 
where  one  of  the  main  objects  is  to  reduce  and  remove,  if  possible, 
the  disfiguring  swellings. 

The  initial  therapeutic  dose  I  employ,  is  small  enough  to 
guarantee  the  absence  of  any  visible  or  appreciable  reaction. 
I  will  give  here  a  few  figures  to  demonstrate  the  size  of  the  initial 
dose  as  I,  as  a  rule,  give  it,  using  exclusively  Koch's  old  tuber- 
culin: 

Initial  Doses  0.  T. 

Under  5  years  1/25000  m.g. 

5  to  10  years  1/20000 

10  to  15  years  1/15000 

15  to  20  years  i/ioooo 

Adults  i/ioooo 

These  doses  are  now  gradually  increased,  the  physician  always 
being  on  the  lookout  for  possible  reaction  phenomena.  Per- 
sonally, the  author  recommends  a  very  conservative  increase 
in  dosage,  as  a  rule  limiting  himself  to  one  of  10%.  Particular 
attention  is  called  to  the  fact  that  the  dosage  is  increased  in  a 
geometrical  progression.  The  interval  between  doses  depends 
upon  the  individual;  as  a  rule,  two  doses  can  be  administered 
each  week.  This  is  especially  true  during  the  first  few  months 
of  treatment.  Later,  when  the  doses  become  larger,  the  interval 
may  be  lengthened  to  5,  6  or  7  days,  never  losing  sight  of  the 
individualistic  character  of  the  treatment. 

How  long  should  the  tuberculin  treatment  be  kept  up?  Until 
the  patient  gets  well!  This  statement,  of  course,  is  subject  to 
many  modifications.  It  depends  mainly  upon  the  individual. 
During  the  course  of  a  tuberculin  treatment  we  see  how  the 


TREATMENT 


169 


patient  gradually  is  improving.  He  begins  to  look  better,  feel 
better  and  gain  in  weight.  The  local  manifestations  begin  to 
disappear,  sinuses  heal  and  glandular  swellings  are  reduced. 
Purely  glandular  cases  respond,  as  a  rule,  to  tuberculin  treatment 
within  a  year.  When  pulmonary  complications  are  present  the 
duration  increases.  In  the  author's  series  of  270  cervical  gland 
cases,  without  pulmonary  involvements,  the  average  duration  of 
treatment  was  14  months  and  12  days. 

The  maximum  dose  is  a  variable  quantity.  In  glandular  cases 
I  very  rarely  exceed  one  mg.  It  should  always  be  remembered 
that  tolerance  to  tuberculin  does  not  mean  an  established 
immunity  to  tuberculosis.  This  tolerance  can  be  brought  about 
by  a  more  rapid  increase  in  dosage  than  I  have  recommended. 
But  tuberculin  increases  the  natural  physiological  resources  of 
the  body  to  fight  the  disease.  It  is  our  opinion  that  these  re- 
sources are  best  utilized  by  mild  stimulations  by  means  of  small 
doses  of  tuberculin,  administered  during  a  long  period  of  time. 

The  value  of  tuberculin  in  the  treatment  of  glandular  tuber- 
culosis has  been  pointed  out  time  and  again  by  various  men. 
WiLMS,24  who  has  had  the  opportunity  of  seeing  a  great  number 
of  cases  of  so-called  surgical  tuberculosis  treated  with  tuberculin, 
remarks,  that  tuberculin  not  only  is  suitable  in  the  treatment  of 
these  cases,  but  that  its  use  is  imperative  to  render  the  organism 
more  resistant  toward  the  tuberculous  infection,  and  to  protect 
it  from  recurrences.  His  views  coincide  markedly  with  those 
of  KRAMER  24  who  considers  tuberculin  the  most  important  rem- 
edy in  treating  tuberculosis  in  children,  not  only  the  glandular 
lesion,  but  in  extirpation  of  tuberculosis  in  general. 

Hilus  tuberculosis  has  received  marked  attention  in  the  hands 
of  many  men.  DAUTWIZ'  25  findings  are  of  extreme  interest. 
He  studied  the  results  of  tuberculin  treatment  in  contrast  to 
those  of  hygiene  and  diet  alone,  and  found  how  much  more 
rapid  recovery  was  accomplished  in  the  former.  He  presented 
graphic  illustrations  of  his  findings  by  means  of  X-ray  plates, 
and  showed  how  the  progressive  clinical  improvement  corre- 
sponded to  increase  in  fibrous  tissue  and  encapsulation  of  the 
glands. 


170      TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

KRAMER,  STARK  and  ROHMER  24  also  report  good  results  in 
hilus  tuberculosis. 

BANDELIER  and  ROEPKE  23  find  tuberculin  of  greatest  value  in 
glandular  tuberculosis.  They  have  never  seen  a  gland  break 
down  under  tuberculin  treatment.  Many  others  are  quoted  by 
them,  e.  g.,  Peiper,  Jochman,  Scherer,  Aronade,  Ullman,  Dumas, 
Lawson,  Raw,  v.  Ruck,  Heubner,  Forster  and  Baginski  who  con- 
sider tuberculin  a  remedy  of  first  order. 

From  HAMMAN  and  WOLLMAN  26  may  be  quoted  Ager,  Stoll, 
Philip,  and  Griswold. 

POGUE  24  and  KRAUSE  24  report  good  results  in  fistulous  tracts 
with  smooth  plastic  scarformation. 

In  the  author's  series  of  270  cases  of  tuberculous  cervical 
adenitis,  at  the  discontinuance  of  treatment  234  cases  were 
apparently  cured,  31  cases  improved  and  5  not  benefited.  The 
two  latter  classes  all  had  pulmonary  complications.  Of  the 
31  improved  the  glandular  condition  had  been  arrested  and  the 
pulmonary  lesions  markedly  benefited.  The  first  class  of  cases — 
those  apparently  cured — included  17  that  had  previously  been 
operated  on,  and  20  that  had  one  or  more  discharging  sinuses. 
The  latter  all  healed,  leaving  very  slight  scars. 

Subsequent  examinations  at  the  end  of  6  months,  12  months 
and  24  months  of  traced  cases,  showed  no  relapse  of  the  glandular 
infection  during  the  two  years  following  treatment.  At  the  end 
of  six  months  51  cases  had  been  lost  track  of,  at  the  end  of  12 
months  83  cases,  and  at  the  end  of  24  months  159  cases. 

TABULATION  or  ABOVE  CASES 
At  End  of  Treatment 

Apparently  cured 234 

Improved. 

(Glandular  lesions  arrested,  pulmonary  conditions 

improved) 31 

Not  benefited. 

(Pulmonary  tuberculosis) 5 

Examination  6  Months  after  Discontinuance  of  Treatment 

No  relapse 214 

Not  located 51 


TREATMENT  I?I 

12  Months  after  Treatment 

No  relapse  ........................  zgo 

Active  pulmonary  tuberculosis  ................  2 

Not  located  ..........................  g- 

24  Months  after  Treatment 
No  relapse  ........................  1OI 

Active  pulmonary  tuberculosis  ..........................  5  (3  new  cases) 

Not  located 


DILUTING  OF  TUBERCULIN  AND  PREPARATION  OF  DOSES 

It  is  universally  recognized  that  diluted  solutions  of  tuberculin 
are  not  stable  and  become  inactive  within  a  few  weeks.  Hence, 
the  importance  of  making  fresh  solutions. 

A  i%  dilution  is  made  with  sterile  physiological  saline  solution 
containing  ^2%  phenol.  This  solution  will  keep  for  several  weeks, 
if  kept  in  a  cool  dark  place.  Each  i/io  cc.  of  this  solution  con- 
tains o.ooi  gm.  or  i  mg.  From  this  a  series  of  dilutions  are  pre- 
pared each  by  i/io  the  volume  strength  of  the  former. 

Dilution  Preparation  Contents  of  each  i/io  cc. 


T.O 

o.i  gm. 
100  mg. 

T.I 

I/IOO 

o.i  cc.  T.O  &  0.9  cc. 

diluent 

o.ooi  gm. 
i  mg. 

T.II 

I/IOOO 

o.i  cc.  T.I  &  0.9  cc. 

diluent 

o.oooi  gm. 
o.i  mg. 

T.III 

I/IOOOO 

o.i  cc.  T.II  &  0.9  cc. 

diluent 

o.ooooi  gm. 
o.oi  mg. 

T.IV 

1/100,000 

o.i  cc.  T.III  &  0.9  cc. 

diluent 

o.oooooi  gm. 
o.ooi  mg. 

T.V 

1/1,000,000 

o.i  cc.  T.IV  &  0.9  cc. 

diluent 

o.ooooooi  gm. 
o.oooi  mg. 

From  these  dilutions  any  dose  may  be  prepared.    I  will  give 
you  here  a  few  tables  to  indicate  the  method. 
As  I  have  stated  before,  a  10%  increase  is  recommended. 


172     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 


TABLE  i 

i  . 

i  .  100 
1.210 

1.331 
1.464 
1.610 

I-77I 
1.948 

2-143 
2-357 
2-593 
2-853 
3-138 
3.452 
3-797 
4.177 
4-595 
5  .  054  etc. 


TABLE  2 

0  .  2    cc. 
o.  22 
0.24 
0.26  " 
0.29 
0.32  " 
0.35  " 
0.39  " 
0.43  " 
0.47  " 
0.52  " 
0.57  " 
0.63  " 
0.69  " 
0.76  " 
0.84  " 
0.92  " 

1  . 


In  the  above  table  it  is  shown  that  the  i8th  dose  approximately 
represents  5  times  the  initial,  hence  the  dose  increases  5  times 
with  each  17  doses.  We  will  use  0.2  cc.  as  our  unit  of  dosage. 
Hence,  using  Table  2  as  our  dose  indicator  we  can  increase  our 
dose  from  0.2  cc.  to  i  cc.,  using  the  same  dilution. 

TABLE  3. 
Initial 

Dose  i8th          35th      sznd    6gth     86th    loyrd, 

1/25000  mg.  |  1/5000  ]  i/iooo  |  1/200  (  1/40  |  1/8    |    5/8    |  io8th-i  mg. 
1/20000  mg.  |  1/4000  |  1/800    |  1/160  |  1/32  |  5/32  |  25/32  |  io6th-i  mg. 
1/15000  mg.  |  1/3000  |  1/600    [  i/i2o[  1/24  |  5/24  |  i  mg.     (Appr.)  _ 
i/ioooo  mg.  1  1/2000  |  1/400    |  1/80    |  1/16  [  5/16  |  98th      (Appr.)  i  mg. 

Let  us  now  carry  the  initial  dose  of  1/25000  mg.  up  to  i  mg.  by 
means  of  a  10%  increase. 

2  ,    rn        ,       8  ,.,  IO      .         2  I 

—  cc.  of  Tv+  —  cc.  diluent  =  —   —  cc.  =  -  mg. 
10  10  10      10          25000 

(According  to  dilutions  —  cc.   of  Tv  contains  -  mg.  of  0.  T. 

IO  IOOOO 


2  ,  2 

—  hence 


10 


i    ,     ,  .  ,   .       i  x 

-  of  which  is  -  mg.) 
10000      5  25000 


TREATMENT  173 

Using  this  solution  for  the  first  18  doses,  the  10%  increase  is 
insured  by  following  Table  2.  The  i8th  dose  is  1/5000. 

Using  solution  Tv— 0.2  cc.  of  which  contains  1/5000  mg.  we  pro- 
ceed according  to  scale. 

The  i8th  dose  of  this  solution  is  i/iooo  mg.,  etc. 

TABLE  4 

No.  of  Dose 

0.2  cc.  of  TV  +0.8  cc.  dil.  =     i  cc.. '.0.2  cc.  =  1/25000  i 

Using  Solution  Tv                             .'.0.2  cc.  =  1/5000  18 

i  cc.  of  TJV      +i      cc.  dil.  =     2  cc..'.o.2  cc.  =  i/iooo  35 

0.25  cc.  of  Tm+o.75  cc-  dil.  =    i  cc..'.o.2  cc.  =  1/200  52 

0.2  cc.  of  Tn  +1.4  cc.  dil.  =  1.6  cc..'.o.2  cc.  =  1/40  69 

o.i  cc.  of  Tj    +1.5  cc.  dil.  =  1.6  cc..'.o.2  cc.  =  1/8  86 

0.5  cc.  of  TI    +1.1  cc.  dil.  =  1.6  cc..'.o.2  cc.  =  5/8  103 
Sixth  dose  of  this  latter  solution  equals  i  mg. 

TABLE  5 

No.  of  Dose 

0.3     CC.  Of  Ty     +O.Q     CC.  dil.  =  1.2     CC./.0.2  CC.  =  1/20000  I 

0.2    cc.  of  TIV  +1.4    cc.  dil.  =  1.6    cc..'. o. 2  cc.  =  1/4000  18 

o.i    cc.  ofTm+i.5    cc.  dil.  =  1.6   cc..'.o.2  cc.=  1/800  35 

o.i    cc.  of  Tn   +3.1    cc.  dil.  =  3.2    cc..'.o.2  cc.  =  1/160  52 

0.2    cc.  of  Tn  +i.o8cc.  dil.  =  1.28  cc..'.o.2  cc.  =  1/32  69 

o.i    cc.  of  TI     +1.18  cc.  dil.  =  1.28  cc.. '.0.2  cc.  =  5/32  86 

0.25  cc.  of  T!    +0.39  cc.  dil.  =  0.64  cc..'.o.2  cc.  =  25/32  103 
Fourth  dose  of  this  latter  solution  equals  approximately  i  mg. 

TABLE  6 

No.  of  Dose 

0.4  cc.  of  TV   +0.8    cc.  dil.  =  1.2    cc..'.o.2  cc.  =  1/15000  i 

0.3  cc.  of  Try +1.5    cc.  dil.  =  1.8    cc..'.o. 2  cc.  =  1/3000  18 

o.i  cc.  of  Tm +1.1    cc.  dil.  =  1.2    cc..'.o.2  cc.  =  1/600  35 

0.6  cc.  of  Tm  +0.84  cc.  dil.  =  1.44  cc..'.o.2  cc.  =  1/120  52 

0.3  cc.  of  Tn  +1.14  cc.  dil.  =  1.44  cc..'.o.2  cc.  =  1/24  69 

0.5  cc.  ofTx    +4.3    cc.  dil.  =  4.8    cc..'.o.2cc.  =  s/24  86 
Eighteenth  dose  of  this  solution  equals  approximately  i  mg. 

TABLE  7 

No.  of  Dose 

0.5  cc.  of  TV  +0.5    cc.  dil.  =  i.     cc./.o. 2  cc.  =  1/10000        i 

0-4  CC.  Of  Tnr    +1.2     CC.  dil.  =  1.6     CC..'.O.2  CC.  =  1/2000  l8 

0.2  cc.  of  Tra  +1-4   cc.  dil.  =  1.6    cc..'.o.2  cc.  =  1/400  35 

o.i  cc.  of  Tn  +i-5    cc.  dil.  =  1.6   cc..'.o.2  cc.  =  i/8c  52 

0.4  cc.  of  TH  +0.88  cc.  dil.  =  1.28  cc..'.o.2  cc.  =  1/16  69 

0.5  cc.  ofTj    +2.7    cc.  dil.  =  3.2   cc..'.o.2cc.  =  5/i6  86 
Thirteenth  dose  of  this  solution  approximately  equals  i  mg. 


174     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

X-Ray  Therapy. — In  more  recent  times  the  X-ray  has  proven 
to  be  of  value  in  the  treatment  of  tuberculosis  of  the  lymph- 
glands,  and  the  fact  is  becoming  more  generally  recognized. 
During  the  last  few  years  a  profound  study  of  the  action  of  the 
rays,  especially  the  deep  rays,  has  opened  new  possibilities. 

This  has  been  made  possible  by  the  development  of  methods 
for  measuring  the  rays  according  to  which  exact  dosage  may  be 
administered;  and  also  to  the  use  of  the  filter,  which  makes  it 
possible  to  use  the  penetrating  rays  necessary  to  affect  the  deeper 
tissues,  and  without  which  their  use  is  impossible,  because  of  the 
effect  exerted  upon  the  skin.  At  present  it  is  a  valuable  addition 
to  the  therapeutic  measures,  available  in  treating  tuberculous 
glands,  and  the  use  of  the  X-ray  has  been  reported  as  satisfactory 
by  many  authors. 

Produces  Definite  Biologic  Changes. — Exposure  to  the  Roent- 
gen rays  produces  definite  biologic  effects.  Their  action  is  local, 
and  because  of  their  penetrating  power  the  rays  reach  all  the 
cells  in  the  area  treated.  Inflammatory  reactions  often  accom- 
pany the  X-ray  effects,  especially  after  longer  doses  have  been 
administered;  but  the  therapeutic  effect  is  dependent  upon  the 
specific  effect,  although  the  healing  process  may  be  aided  by  the 
inflammation. 

Effect  of  Exposure. — The  tissue  cells  vary  in  regard  to  their 
sensitiveness  to  the  X-ray,  those  most  affected  being  the  ones 
that  are  rich  in  protoplasm  and  with  active  metabolism.  The 
more  highly  specialized  cells  are  affected  first;  pathological  tissues 
composed  of  young  and  rapidly  growing  cells  of  low  vitality 
offer  little  resistance  to  the  rays.  The  more  embryonal  in  type 
is  the  cell,  the  more  easily  it  is  destroyed,  as  is  evidenced  by  the 
effect  exerted  upon  such  tissues  as  sarcomata,  which  cells  are 
typically  embryonal  and  very  sensitive.  Cells  of  diseased  tissue 
are  more  sensitive  than  are  healthy  ones,  and  hyperemic  tissues 
are  more  affected  than  anemic  ones.  Round  celled  infiltrations 
are  easily  destroyed,  while  connective  tissue  is  affected  with 
difficulty.  Lymphoid  cells  are  very  susceptible  to  the  Roentgen 
rays. 

Has  a  Selective  Action. — The  favorable  influence  of  Roentgen 


TREATMENT  175 

therapy  in  tuberculosis  of  the  lymphatic  glands  is  due  in  large 
part  to  this  selective  action  of  the  rays  upon  the  lymphoid  tissue 
of  the  glands,  since  this  tissue  is  in  a  state  of  chronic  inflammation 
and  attended  by  proliferative  changes.  These  cells  are  destroyed 
and  replaced  by  fibrous  tissue  cells,  as  can  be  demonstrated  at 
operation,  or  by  microscopical  examination.  The  lymphatic 
channels  also  become  converted  into  fibrous  tissue,  thus  eliminat- 
ing the  possibility  of  further  spread  of  the  disease  and  isolating 
it  in  the  lymph-nodes,  where  it  is  finally  overcome.  This  de- 
structive effect  upon  the  lymphatic  element,  as  upon  all  cells 
which  have  a  marked  faculty  of  proliferation,  is  the  most  pro- 
nounced action  observed.  The  growth  of  connective  tissue  cells 
is  stimulated  and  cicatrization  follows. 

Action  Distinctive  to  Giant  Cells. — According  to  PIRIE  27  an 
important  factor  is  the  destruction,  by  the  rays,  of  the  rapidly 
developing  giant  cells.  Sections  of  the  giant  cells,  observed  in 
microscopic  preparations,  often  show  tubercle  bacilli,  and  he 
believes  that  these  cells  become  inactive  and  constitute  a  place 
where  the  bacilli  can  live  unharmed  by  the  leucocytes.  By  the 
destruction  of  these  cells  the  bacilli  are  deprived  of  this  protec- 
tion, and  can  then  be  destroyed  by  the  leucocytes.  With  this 
in  view  he  makes  use  of  the  maximum  dose  the  skin  will  stand, 
at  intervals  of  a  week.  This  dose  destroys  the  giant  cells,  which 
may  form  in  a  week's  tune,  and  this  same  dose  according  to 
PIRIE,  only  stimulates  the  attacking  leucocytes.  The  question 
arises,  whether  the  Roentgen  rays  have  any  direct  action  on 
the  tubercle  bacillus.  This  is  usually  considered  as  a  negligible 
factor;  and  experiments  upon  guinea-pigs,  quoted  by  BROCA 
and  MAHAR,28  seem  to  invalidate  any  such  hypothesis. 

Effect  on  the  Opsonic  Index. — There  are  some  grounds  for 
believing  that  irradiation  may  produce  serological  changes  in 
the  organism  so  treated.  This  may  account  for  the  observation 
occasionally  made  of  the  disease  in  size  of  neighboring  or  distant 
similarly  affected  glands,  when  treatment  is  directed  to  tuber- 
culous cervical  glands.  The  systematic  effect  has  also  been 
studied  by  its  effect  upon  the  opsonic  index.  It  has  been  shown 
that  the  index  rises  as  treatment  progresses,  but  that  it  will  fall 


1 76    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

into  the  negative  phase  and  the  progress  of  healing  will  be  re- 
tarded, if  treatment  is  too  severe.  The  opsonic  index  changes 
more  slowly  and  does  not  show  such  sudden  variations  as  are 
caused  by  tuberculin.  These  facts  show,  that  the  treatment 
must  begin  intelligently  and  proper  dosage  be  administered,  if 
the  best  results  are  to  be  obtained.  If  the  dosage  is  too  large  a 
general  reaction  may  result,  evidently  due  to  changes  in  the  blood 
serum  or  to  toxemia  resulting  from  tissue  destruction. 

KIENBOECK  29  attributes  the  destruction  of  cells  to  a  recession 
of  metabolic  activity.  RICHARD  has  studied  the  effect  of  the 
X-ray  upon  enzyme  action  and  found  that  slight  exposures  in- 
creased enzyme  action,  while  greater  exposures  were  inhibitive 
or  destructive.  He  believes  that  the  direct  injury  to  the  chroma- 
tion  of  the  cells  is  undoubtedly  important,  but  that  changes  in 
enzyme  action,  resulting  from  the  action  of  the  rays,  likewise 
plays  a  considerable  part  in  the  resulting  injury. 

Healing  Action. — The  action  of  the  Roentgen  rays  in  producing 
healing  in  tuberculous  glands  is  then  dependent  upon  several 
factors.  They  bring  about  actual  destruction  of  the  tuberculous 
granulation  tissue,  as  has  been  uniformly  demonstrated  by  the 
microscopic  examination  of  irradiated  tubercles.  Epithelioid  and 
giant  cells  become  degenerated,  shrunken  and  finally  disinte- 
grated and  are  replaced  by  a  proliferation  of  fibroblasts,  which  are 
stimulated  by  the  rays.  The  rays  also  cause  a  certain  amount 
of  reaction  in  the  surrounding  tissues,  resulting  in  hyperemia 
and  crowding  of  the  vessels  surrounding  the  lesion  with  leuco- 
cytes, which  promote  absorption  of  the  inflammatory  products, 
and  in  infiltration  of  the  tissues  with  small  round  cells,  which 
wall  off  the  diseased  areas  by  connective  tissue  formation  and 
thus  favor  healing.  The  theories  have  also  been  proposed,  that 
the  X-rays  have  an  autotuberculin  or  autovaccin  effect  due  to  the 
liberation  of  tuberculin  by  degeneration  of  the  tubercles,  or  that 
the  effect  upon  the  bacilli  may  lessen  the  toxin  formation,  or 
bring  about  a  chemical  change  in  the  toxin. 

A  Valuable  Therapeutic  Agent. — The  X-ray  is  a  valuable 
therapeutic  agent,  whether  used  alone  or,  better,  combined  with 
tuberculin  treatment.  It  is  preferable  to  surgical  treatment 


TREATMENT  177 

over  which  it  possesses  numerous  advantages.  It  can  be  used 
to  great  advantage  in  those  cases  where  the  poor  nutrition  of  a 
patient  may  preclude  operative  interference.  It  is  painless  and 
avoids  the  shock  and  the  dangers  of  an  extensive  dissection  of 
the  glands  which  often  requires  a  long  and  tedious  operation. 
The  glands  are  reduced  to  hard  fibrous  nodules  and  the  lymphatic 
channels,  by  means  of  which  the  tuberculous  infection  spreads 
from  gland  to  gland,  are  transformed  into  fibrous  cords. 

Protective  Action. — This  sclerosis  of  blood  and  lymphatic 
vessels,  in  the  area  subjected  to  irradiation,  is  the  best  safeguard 
against  the  further  spread  of  infection.  Furthermore,  the  pen- 
etrating power  of  the  rays  enable  them  to  thoroughly  reach  all 
diseased  glands  in  the  irradiated  area,  thereby  treating  glands 
that  may  be  overlooked  by  the  operator  in  making  an  excision. 
Roentgen  therapy  also  treats  effecitvely  those  glands  which  are 
infected  but  show  no  enlargement  or  other  visible  evidence  of 
their  infection.  By  some  the  X-ray  is  used  in  conjunction  with 
surgery  and  may  be  considered  as  a  valuable  aid.  If  a  radical 
operation  is  done,  the  use  of  the-X-ray  following  operation  may 
lessen  the  chances  of  recurrences,  and  in  incomplete  operations 
the  rays  may  then  effect  a  complete  cure.  In  advanced  cases 
with  sinuses  and  with  matting  of  the  tissues  a  radical  operation 
may  be  precluded,  and  in  such  cases  the  X-ray  may  heal  the  si- 
nuses and  promote  a  cure.  If  the  cases  are  seen  early  the  scars 
of  healed  sinuses  or  operations  may  be  avoided  and  a  perfect 
cosmetic  effect  obtained,  the  tanning  of  the  skin  disappearing 
in  due  time.  With  Roentgen  therapy  the  patient  does  not  need 
to  be  confined  to  a  hospital,  and  can  be  following  out  the  proper 
hygienic  and  dietetic  re'gime. 

The  Technique. — The  technique  employed  by  various  Roent- 
genologists  differs  in  its  details,  but  the  principles  involved  are 
the  same.  I  shall  not  discuss  the  technique  of  Roentgen  therapy 
in  detail,  for  it  may  be  found  in  works  devoted  to  that  subject. 
The  effect  is  produced  by  the  rays  absorbed,  and  the  object  of 
treatment  should,  therefore,  be  to  cause  the  greatest  possible 
absorption  of  rays  by  the  diseased  tissues.  This  does  not  imply 
that  we  should  employ  the  highest  possible  doses,  but  that  the 


1 78    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

highest  possible  concentration  of  rays  should  be  upon  the  dis- 
eased tissue,  with  the  minimum  of  absorption  where  it  is  not 
desired.  Since  the  skin  is  the  most  exposed  tissue,  the  problem 
is  to  produce  an  effect  upon  the  underlying  tissues  without  injury 
to  the  integument.  To  obtain  this  result  a  tube  with  a  pene- 
tration of  Number  6  Benoist,  producing  hard  rays,  is  employed. 
They  have  a  maximum  penetrating  power  and  are  absorbed  to 
the  least  degree  by  the  skin.  But  the  most  satisfactory  results 
cannot  be  obtained  by  this  method  alone;  and  in  addition  to 
this,  a  filter  must  be  employed -to  absorb  the  soft  rays,  which 
have  little  penetrating  power  and  are  absorbed  by  the  skin.  For 
this  purpose  various  substances  are  interposed  between  the  tube 
and  the  skin  to  intercept  the  passage  of  the  soft  rays;  some 
workers  use  a  plate  of  aluminum  i  to  2  mm.  thick;  others  employ 
tin  foil,  or  sole  leather.  The  exposed  area  should  extend  wide 
of  the  disease  and  the  surrounding  tissues  be  protected  by  lead 
foil.  In  the  neck  the  entire  region,  from  the  mastoid  process 
above  down  to  and  including  the  apex  of  the  lung,  should  be 
subjected  to  irradiation. 

Dose  Employed. — The  dosage  employed  also  varies,  some  pre- 
ferring a  massive  dose  at  long  intervals,  and  others,  smaller  doses 
more  frequently  repeated.  The  best  results  are  obtained  when 
the  dosage  is  accurate:  it  should,  therefore,  be  controlled  by 
Sabourand's  pastilles,  or  other  methods  of  measuring  the  quan- 
tity of  rays  applied  to  the  affected  area. 

Erythema  Dose. — KIENBOECK  ^  employed  a  hard  tube,  with  a 
penetration  above  Benoist  Number  6,  at  a  distance  of  20  to  30 
cm.,  and  a  filter  of  aluminum,  glass  or  hard  leather.  When  possi- 
ble, he  irradiates  from  various  sides  or  angles.  This  so-called 
"cross-firing"  method  is  advantageous,  for  the  diseased  area  may 
be  treated  and  a  different  skin  area  exposed  each  time,  thus  ob- 
taining the  maximum  absorption  of  rays  where  it  is  desired,  and 
with  minimum  damage  to  the  integument.  He  usually  applies  the 
maximum  superficial  dose,  called  also  the  erythema,  normal  or 
epillation  dose;  and  repeats  it  in  three  or  four  weeks,  continuing 
treatment  over  months  until  cure  is  accomplished.  Giving  max- 
imal doses  at  one  sitting  permits  of  more  accurate  control  of  the 


TREATMENT  179 

dose.  Where  the  application  of  the  rays  necessitates  the  use  of  a 
greater  skin  distance  and  harder  rays,  he  commends  a  modified 
method  and  divides  the  maximal  dose  over  succeeding  days,  or 
gives  one-third  the  full  dose  every  eight  to  fourteen  days. 

PIRIE  29  employs  a  filter  and  gives  one-third  the  dose  required 
to  produce  epillation,  as  measured  by  Sabourand's  pastilles,  at 
intervals  of  a  week. 

HUBENY'S  method  consists  of  the  administration  of  one-half 
an  erythema  dose,  seven  to  eight  Wehnult,  plus  four  mm.  of 
aluminum,  repeated  three  successive  times  at  two  weeks  inter- 
vals, then  twice  at  three  weeks  intervals,  gradually  increasing 
the  intervals  between  treatments  until  about  eight  treatments 
have  been  given. 

H.  MOWAT  31  employs  rays  obtained  by  the  use  of  a  hard 
tube  and  current  of  two  or  three  milliampe'remeters  and  a  filter 
of  1.5  mm.  of  aluminum..  He  gives  an  exposure  of  at  least  one 
full  Sabourand  dose  once  or  twice  weekly. 

Dose  for  Children. — 0.  H.  PETERSEN  32  irradiates  with  hard 
rays  obtained  by  means  of  an  aluminum  filter  3  mm.  thick, 
thereby  securing  much  better  and  more  uniform  depth,  action, 
and  better  skin  protection.  As  a  single  dose  for  adults  and  older 
children  be  employs  one-half  of  the  maximal  dose.  For  younger 
children  he  diminishes  the  dose  according  to  age.  He  repeats 
the  dose  in  the  beginning  every  four  weeks,  and  in  the  further 
course  of  the  treatment,  allows  longer  intervals  between  ex- 
posures. 

TIXIER  33  applies  3^  Holzknecht  units  every  eight  to  fourteen 
days. 

TONSEY  34  states  that  tuberculous  glands  are  readily  amenable 
to  treatment  by  a  radiance  with  penetration  of  Benoist  Number 
5  or  Number  6.  He  gives  short  applications  of  about  i-^ 
minutes  at  a  distance  of  9  inches  from  the  anticathode,  three 
times  a  week  until  some  reaction  appears,  when  the  treatment 
should  be  intermitted.  Each  application  should  be  calculated  to 
be  a  little  less  than  one  Holzknecht  unit.  Another  plan  is  to 
make  massive  application  of  4  or  5  H.  units  at  a  single  session, 
or  two  or  more  within  the  course  of  two  or  three  weeks. 


i8o     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

Dangers. — There  are  certain  dangers  attending  the  use  of  the 
X-ray,  and  it  should  be  employed  only  by  one  skilled  in  its  appli- 
cation for  therapeutic  purposes.  The  treatment  is  often  stretched 
out  over  a  long  period  of  tune,  and  the  cumulative  effect  of  the 
rays  must  be  avoided,  for  it  may  produce  severe  reaction  and 
injury  to  the  skin  at  a  remote  time,  although  each  individual  dose 
has  been  below  the  border  of  danger.  According  to  ISELIN  35 
the  danger  border  for  the  neck  lies  at  about  six  full  Sabourand 
doses  filtered  through  one  mm.  of  aluminum.  A  common  expe- 
rience is  the  diminution  of  the  glandular  swellings  as  a  result  of 
the  late  action  of  the  rays.  Hence,  in  difficult  cases  six  exposures 
of  maximal  dosage  may  be  given  at  intervals  of  one  month 
followed  by  an  interval  of  several  months  to  await  the  late  action 
of  the  rays. 

The  Local  Reaction. — Following  exposure  there  is  a  local 
reaction  in  the  glands.  It  occurs  very  soon  and  lasts  for  a  va- 
riable period  of  time.  It  may  be  very  slight  or  consist  in  swelling 
of  the  glands  and  painfulness  in  the  treated  area.  The  discom- 
fort is  usually  not  so  very  marked.  With  the  more  massive  doses 
there  may  be,  in  addition,  a  general  reaction  characterized  by 
malaise,  nausea  and  vomiting  appearing  soon  after  the  exposure. 
Such  reactions  call  for  a  more  careful  regulation  of  the  dose. 

Valuable  in  Earlier  Stages. — As  with  other  methods  of  treat- 
ment, Roentgen  therapy  is  especially  indicated  in  the  early 
stages  of  the  disease  before  caseation  and  suppuration  have 
occurred.  The  most  favorable  cases  for  treatment  are  those 
which  are  not  so  far  advanced,  especially  in  children  and  young 
adults,  where  the  glands  are  palpable  as  firm  hyperplastic  nodules. 
In  the  later  stage,  where  the  glands  have  become  adherent 
forming  a  mass,  the  first  effect  of  treatment  noted  is  a  lessening 
of  the  periadenitis,  and  the  glands  that  were  agglomerated  be- 
come isolated.  Hyperplastic  glands  enlarge  after  an  exposure 
to  the  Roentgen  ray;  later  they  decrease  markedly  in  size,  the 
extent  to  which  they  subside  depending  upon  their  previous 
state  of  inflammation.  The  retrogression  may  be  sufficient  to 
cause  complete  disappearance  of  the  nodes,  but  more  often  the 
glands  persist  as  small  palpable  innocuous  fibroid  nodules,  which 


TREATMENT  181 

never  entirely  disappear.  X-ray  therapy  is  not  confined  to  the 
earlier  forms,  although  it  is  in  these  that  the  best  results  are  ob- 
tained. Older  glands  which  are  about  to  undergo  caseation,  or 
in  which  caseation  has  begun,  are  less  favorable  to  treat  and 
softening  is  often  hastened.  Aspiration  or  incision  are  then  re- 
quired to  remove  the  pus,  after  which  treatment  may  be  resumed. 
TONSEY  has  observed  excellent  results  from  the  use  of  the  X-ray 
in  suppurating  tuberculous  glands,  opened  spontaneously  or  by 
the  surgeon's  knife. 

Fistulas  do  not  Yield. — The  ulcerating  and  fistulous  forms 
are  the  most  difficult  and  the  least  favorable  for  treatment. 
Secondary  infection  is  usually  present,  but  in  spite  of  this  the 
fistulae  may  close  up,  the  ulcers  heal,  the  glandular  swellings 
disappear,  the  infiltration  becomes  less  in  amount,  and  the  dis- 
charge changes  from  a  purulent  to  a  serious  character.  The  fis- 
tulae close  with  difficulty  after  prolonged  treatment,  but  leave 
better  scars  than  those  cases  healing  spontaneously. 

Patients  with  repeated  occurrences  after  operation,  or  in  whom 
ulcerations  and  sinuses  still  persist,  can  be  successfully  treated. 
With  a  subsidence  of  the  local  disease  the  general  health  of  the 
patient  improves,  his  appetite  returns,  and  he  gains  in  weight 
and  strength. 

In  the  hands  of  Roentgenologists,  who  have  used  an  accurately 
measured  dosage,  we  find  uniform  reports  of  success  with  a  large 
percentage  of  cures  and  a  scarcity  of  recurrences. 

Views  of  Investigators. — PHILIPOWICZ  36  finds  the  X-ray  most 
satisfactory  in  treating  tuberculous  adenitis.  He  finds  that  at 
least  six  months'  time  is  necessary  for  treatment.  The  nodes 
subsided  completely  or  remained  as  small  dense  fibroid  nodules. 
Fistulae  healed  with  flexible  scars. 

ISELIN  37  reports  206  cases  of  glandular  tuberculosis  treated 
with  the  X-ray  with  complete  cure  in  133,  and  improvement  in 
all  but  4  cases. 

ROQUES  38  considers  the  X-ray  to  be  the  treatment  of  choice. 

O.  H.  PETERSEN  39  concludes,  that  no  glandular  tuberculosis 
is  absolutely  refractile  to  treatment  with  the  X-ray,  but  advises 
that  it  be  combined  with  other  measures  and  not  used  alone. 


1 82     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

BROCA  and  MAHAR  K  report  79  cases,  45  of  which  were  open 
and  suppurating.  In  36  cases  they  obtained  complete  healing. 
In  24,  marked  improvement,  and  in  19  there  was  some  improve- 
ment but  treatment  was  interrupted.  They  never  used  over  six 
exposures  and  found  that  incision  of  the  softened  glands  was  of 
value  in  hurrying  the  healing. 

FRITSCH  w  submitted  33  cases  to  this  treatment.  In  the 
absence  of  tuberculosis  elsewhere  he  considers  the  treatment 
very  effectual.  He  sees  advantages  in  combining  6  months  of 
X-ray  with  other  treatment. 

Good  results  have  been  reported  by  BLAiscH,41  MowAT,31 
ToNSEY,34  VON  MuTSENBACHER,42  BERGONiE  43  and  others. 

TONSEY  34  considers  tuberculous  mediastinal  glands  amenable 
to  treatment  by  Roentgenotherapy.  He  employs  a  radiance  with 
an  intensity  of  Benoist  Number  6;  the  anticathode  is  placed  13 
inches  from  the  chest  and  a  piece  of  sole  leather,  or  an  aluminum 
filter,  to  intercept  the  soft  rays.  He  gives  exposures  of  3 
minutes'  duration  twice  a  week  with  intermissions  on  the  devel- 
opment of  some  erythema  of  the  skin.  Massive  doses,  he  be- 
lieves, are  less  desirable  than  milder,  frequently  repeated  ones. 
The  results  are  variable,  but  it  is  capable  of  great  benefit  in 
certain  cases. 

Surgical  Treatment. — Tuberculosis  of  the  lymphatic  glands 
has  always  been  classed  under  the  heading  of  "Surgical  Tuber- 
culosis," and  various  surgical  procedures  have  been  advised  and 
employed  in  its  treatment.  The  surgical  treatment  must  vary 
according  to  the  pathological  conditions  which  present  them- 
selves as  indications  for  treatment.  All  gland  groups  are  not 
amenable  to  surgical  intervention;  for  example,  the  bronchial 
glands,  by  reason  of  their  deep-seated  location  within  the  thorax, 
cannot  be  reached  by  the  knife.  Various  procedures  are  classed 
under  the  heading  of  surgical  treatment,  and  we  shall  consider 
excision,  aspiration,  incision,  currettement,  and  injections  into 
the  glands. 

Excision. — Under  the  heading  of  excision  of  tuberculous 
lymph-glands,  I  shall  first  consider  the  so-called  radical  operation 
which  aims  at  the  cure  of  tuberculosis  by  eliminating  from  the 


TREATMENT  183 

organism  all  infected  glands  by  means  of  an  extensive  dissection. 
As  an  example  of  this  method  of  procedure,  we  may  discuss  the 
well-known  operation  for  tuberculous  cervical  nodes.  This 
operation  was  formerly  used  extensively  and  no  class  of  cases 
was  considered  more  within  the  realm  of  the  surgeon's  care. 

At  the  present  time  the  ideas  of  surgical  treatment  of  this 
condition  are  becoming  more  and  more  conservative,  and  atten- 
tion is  being  turned  to  methods  of  treatment,  such  as  we  have 
outlined  above,  rather  than  to  extensive  dissections.  This  I 
consider  as  an  advancement  in  our  methods  of  treatment  of 
glandular  tuberculosis,  and  although  there  are  surgeons  who  still 
advise  and  employ  methods  of  dissection,  I  believe  them  to  be 
contraindicated  and  productive  of  poorer  results  than  conserv- 
ative and  specific  treatment.  I  shall  not  consider  the  technique 
in  detail;  this  may  be  found  in  works  on  surgery.  An  incision 
is  made  either  parallel  to  the  natural  folds  of  skin  in  the  neck,  or 
along  the  margin  of  the  Sterno-cleido-mastoid  muscle.  The 
incisions  must  be  free,  for  the  glandular  involvement  is  extensive, 
always  more  so  than  it  appears  to  be  from  external  examination. 
Flaps  of  skin  and  the  Platysma  muscle  are  reflected  and  the  field 
exposed.  Then  by  the  knife  and  blunt  dissection  the  surgeon 
attempts  to  remove,  as  completely  as  possible,  all  infected  glands 
without  injury  to  the  many  important  structures  found  in  the 
neck.  The  operation  is  difficult,  to  say  the  least,  and  can  only 
be  performed  thoroughly  by  a  well-qualified  surgeon.  The  opera- 
tion is  often  a  lengthy  one  as  time  and  care  are  required  in  freeing 
infected  glands  which  are  adherent  to  the  internal  jugular  vein, 
or  imbedded  firmly  about  important  nerves.  Glands  are  often 
ruptured  in  removal  and  infectious  material  contaminates  the 
wound.  The  operation  means  the  loss  of  more  or  less  blood. 
If  the  operation  is  performed  with  an  aseptic  technique,  healing 
readily  occurs  with  the  usual  scar  at  the  site  of  incision. 

Operation  Serious  in  Children. — The  operation  is  not  a 
trivial  one  to  be  undertaken  lightly,  and  it  is  attended  by  a 
certain  risk.  Many  of  the  cases  presenting  themselves  for  treat- 
ment are  in  children  who,  as  the  result  of  their  long-standing 
tuberculous  infection,  are  anaemic  and  poorly  nourished.  Such 


184    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

children  are  very  sensitive  to  the  loss  of  blood  and  unless  proper 
attention  has  been  paid  to  preliminary  treatment,  death  may 
ensue.  Surgeons,  however,  are  familiar  with  the  value  of  this 
preoperative  treatment  in  building  up  the  strength  of  the  patient, 
increasing  the  resistance,  improving  his  nutrition  and  raising 
his  hemoglobin  index,  and  the  mortality  in  the  hands  of  expe- 
rienced men  has  not  been  high.  Surgeons  also  recognize  the 
necessity  of  subsequent  or  post-operative  treatment  in  these 
cases.  In  my  opinion  if  these  general  measures  were  but  com- 
bined with  tuberculin  therapy,  properly  administered,  the 
surgical  part  of  the  treatment  might  be  largely  dispensed  with. 

Infected  Glands  may  not  all  be  Enlarged. — We  must  consider 
the  possibility  of  the  removal  by  dissection  of  all  the  diseased 
glands,  for  the  conception  of  the  operation  is  based  upon  the 
opinion,  that  by  timely  operative  interference  the  foci  of  infec- 
tion may  be  removed.  We  should  remember  that  the  glandular 
infection  is  always  more  extensive  than  it  appears  to  be,  and  the 
lymphatic  glands  of  the  region  of  the  neck  are  especially  numer- 
ous. Very  often  we  see  a  fine  multiple  enlargement  of  the  cervical 
nodes.  BARTELS  and  others  have  shown  that  glands  may  be 
infected  and  show  no  pathological  changes,  the  infection  being 
demonstrable  only  by  animal  inoculation.  It  is  to  be  seen  that 
such  glands  might  easily  be  overlooked  in  making  an  extensive 
dissection  in  a  case  presenting  a  multiple  spreading  involvement 
of  the  nodes.  A  radical  removal  by  dissection  of  all  diseased 
glands  may,  therefore,  be  considered  an  impossibility. 

Bronchial  Glands  also  may  be  Enlarged. — The  possibility  of 
the  presence  of  tuberculosis  elsewhere  must  be  borne  in  mind. 
Careful  examination  often  reveals  infected  bronchial  glands, 
or  a  pulmonary  involvement.  In  such  cases  the  infection  of  the 
cervical  lymphatic  glands  is  but  a  part  of  the  tuberculous  in- 
fection, from  which  the  individual  is  suffering,  and  operative 
treatment  of  these  glands  may  reduce  the  patient's  resistance 
to  such  an  extent  that  the  other  foci  may  increase  their  activity, 
and  the  result  be  disastrous.  We  are  too  prone  to  consider  tuber- 
culous glands  simply  as  a  chronic  adenopathy  rather  than  as  a 
manifestation  of  tuberculosis.  Surely  it  is  just  as  important  to 


TREATMENT  185 

recognize  and  treat  tuberculosis  as  such,  when  it  affects  the 
lymphatic  glands,  as  when  it  affects  other  organs  of  the  body. 
I  consider  tuberculosis  of  the  lymphatic  glands  as  a  medical 
disease  and  treat  it  as  such. 

In  surgical  treatment,  by  means  of  a  radical  operation,  the  only 
glands  treated  are  those  which  have  been  removed.  The  imme- 
diate results,  as  far  as  the  disfigurement  caused  by  a  large  mass 
of  glands  is  concerned,  is  usually  satisfactory  and  in  some  cases 
the  operation  may  fairly  be  described  as  successful.  But  in  nu- 
merous instances,  the  effect  of  the  operation  can  only  be  a  partial 
one,  from  the  nature  of  the  pathological  condition  with  which 
we  are  dealing,  for  it  is  obviously  impossible  to  remove  all  the 
infected  glands.  Even  when  the  manifestly  diseased  glands 
have  been  removed,  the  final  cure  is  brought  about  in  the  same 
way  as  with  general  hygienic  and  specific  treatment.  The 
amount  of  infection  with  which  the  patient  is  contending  is 
diminished,  but  the  surgical  procedure  has  not  eradicated  his 
tuberculosis.  There  can  scarcely  be  a  doubt  that  the  cure  of 
tuberculosis  by  any  one  method  of  treatment  is,  in  the  end, 
brought  about  by  the  natural  processes  of  healing.  We  must, 
therefore,  employ  those  measures  which  will  be  of  greatest  aid 
to  these  natural  healing  processes. 

Operations  May  Assist. — We  must,  therefore,  consider  the 
question  of  radical  operation,  not  as  a  means  of  absolute  cure, 
but  merely  as  an  adjunct  to  our  methods  of  treatment  and  ques- 
tion if  this  removal  of  the  part  of  the  infected  tissue,  by  means 
of  a  mutilating  operation,  is  the  best  means  at  our  command  for 
assisting  the  organism  to  combat  its  tuberculosis.  The  combina- 
tion of  general  hygiene  and  tuberculin  treatment,  as  I  have  out- 
lined, aims  at  the  increase  of  the  resistance  of  the  body  to  tuber- 
culous infection  by  the  development  of  toximmunity,  and  a 
stimulation  of  the  factors  of  healing.  In  tuberculin  treatment 
we  are  treating  every  gland  that  may  be  infected  with  tuberculo- 
sis, as  well  as  tuberculous  foci  elsewhere  in  the  body,  if  such 
happen  to  exist  as  they  not  infrequently  do.  In  the  surgical 
treatment  the  glands  which  have  been  removed  are  the  only  ones 
treated.  The  very  success  of  the  operative  treatment  in  some 


1 86    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

cases  has  diverted  attention  from  the  tuberculous  infection  as 
such,  and  the  final  result  in  many  cases  has,  therefore,  been  dis- 
appointing. The  mutilating  operation  cannot  but  lower  the 
local  and  general  resistance  to  infection,  in  this  respect  being 
opposed  to  tuberculin  therapy.  In  numerous  instances,  in  which 
the  operation  has  seemed  immediately  successful,  disfiguring 
enlargement  has  recurred  and  not  infrequently  with  suppuration, 
and  often  have  I  observed  cases  where,  after  repeated  operations, 
enlargement  of  the  glands  continued  to  reappear  with  a  gradual 
extension  of  the  infection  downward  and  more  deeply.  I  have 
seen  many  cases  in  which  an  extensive  operation  has  been 
performed  for  deep  lying  diseased  glands,  and  where  little  relief 
has  followed,  or  the  disfigurement  of  the  group  of  glands  removed 
was  soon  replaced  by  enlargement  of  another  group,  often  those 
on  the  opposite  side  of  the  neck.  (See  Plates  XI  and  XII).  I 
have  had  cases  present  themselves  to  me  for  treatment  with  a 
large  mass  of  glands,  causing  great  disfigurement  and  ill  health, 
who  gave  a  history  and  showed  the  scars  of  three  or  four  opera- 
tions. After  having  submitted  to  repeated  operations  these  pa- 
tients still  had  their  tuberculous  glands,  because  all  those  infected 
had  not  been  removed  and  there  had  not  been  sufficient  treat- 
ment directed  to  the  assistance  of  the  natural  processes  of  heal- 
ing. In  such  cases  the  infection  has  subsided,  and  the  glandular 
enlargement  gradually  disappeared,  not  to  recur  under  the  in- 
fluence of  tuberculin  properly  administered.  The  physician  is 
frequently  called  upon  to  treat  these  cases  which  have  not  been 
cured  by  radical  operation.  I,  therefore,  believe  it  is  safer  and 
wiser  to  make  use  of  the  same  treatment  in  tuberculous  glands 
that  we  would  institute  in  other  forms  of  tuberculosis.  The 
value  of  tuberculin  cannot  be  denied,  and  many  clinicians  will 
testify  to  its  use  in  the  treatment  of  tuberculous  adenitis. 

Value  of  Early  Operation. — Surgeons  favor  early  operation 
before  caseation  and  suppuration  have  occurred.  Surely  the 
best  results  are  to  be  obtained  by  any  method  of  treatment  when 
it  is  applied  early.  After  caseation  and  suppuration  have  oc- 
curred, surgical  measures  may  become  necessary,  as  tuberculin 
will  not  do  the  impossible,  namely,  remove  the  necrotic  tissue. 


TREATMENT  187 

But  simpler  measures  than  a  radical  operation  suffice  in  these 
cases  of  suppuration  and  abscess  formation.  One  of  the  ar- 
guments for  early  surgical  intervention  is  to  prevent  the  oc- 
currence of  suppuration,  but  it  must  be  admitted  that  this 
is  not  the  usual  termination  of  all  cases  of  tuberculosis  of  the 
lymphatic  glands.  In  cases  allowed  to  run  their  course  prob- 
ably only  about  one-half  terminate  in  suppuration.  When 
properly  treated  and  treatment  instituted  early,  suppuration 
may  be  considered  as  an  incidental  occurrence  and  it  is  rel- 
atively uncommon  when  we  consider  the  large  number  of 
glands  usually  infected  and  showing  infiltration.  Yet  in  ad- 
vocating radical  surgical  treatment,  attention  has  been  chiefly 
centered  upon  this  incidental  occurrence  and  too  little  upon  the 
tuberculous  infection  per  se.  Rational  treatment  should,  there- 
fore, be  directed  to  the  essential  factor,  the  tuberculous  infection, 
rather  than  to  the  condition  of  suppuration,  which  does  not 
necessarily  occur.  Failure  of  surgical  treatment  has  resulted 
by  direction  of  attention  from  the  more  important  factor, 
and  the  result  has  been  a  limitation  of  operative  treatment  and 
more  attention  to  specific  treatment  and  hygienic  measures 
destined  to  bring  about  healing  in  a  natural  way.  I  believe, 
therefore,  that  we  should  institute  such  treatment  which,  of 
itself,  is  prophylactic  against  suppuration.  While  surgical  re- 
moval of  suppurating  glands  may  be  satisfactory,  it  is  uncertain 
and  gives  no  assurance  that  the  other  glands,  likewise  infected, 
which  have  not  been  removed,  will  not  soon  be  in  the  same  con- 
dition as  the  ones  removed.  Tuberculous  glands  are  amenable 
to  tuberculin  treatment,  and  if  suppuration  should  occur,  or 
be  found  when  the  case  first  presents  itself  for  treatment,  the 
pus  may  be  removed  by  the  simple  method  described  below, 
the  condition  being  still  medical,  not  surgical. 

Tuberculin  Treatment  Leaves  no  Scars. — The  radical  opera- 
tion has  been  favored  by  some  on  the  grounds  that  the  scar  left 
by  operation  is  much  less  disfiguring  than  those  resulting  from 
the  healing  of  fistulae  resulting  from  the  rupture  and  discharge 
of  suppurating  glands.  But  this  argument  presupposes  that 
suppuration  is  inevitable,  and  can  be  remedied  in  no  other  way 


i88    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

which,  as  we  have  shown,  is  far  from  being  the  case  if  the  patients 
present  themselves  before  abscesses  have  ruptured.  If  suppura- 
tion does  occur  it  can  be  treated  by  aspiration,  as  outlined  below, 
and  no  fistulas  need  result,  and  an  extensive  dissection  is  unnec- 
sary.  It  is  surely  better,  as  far  as  cosmetic  results  are  obtained, 
to  treat  a  case  so  that  no  scar  at  all  results  than  to  have  a  scar, 
the  result  of  an  operation,  even  though  it  be  only  slightly  dis- 
figuring. (See  Plate  XIII.)  And  when  we  consider  that  some 
cases  may  have  several  scars  from  repeated  operations,  and  still 
have  a  large  mass  of  suppurating  glands,  I  do  not  think  operation 
is  justifiable  on  the  grounds  that  it  will  cure  and  leave  a  less  un- 
sightly scar. 

The  length  of  time  required  for  tuberculin  treatment  is  nec- 
essarily longer  than  when  surgical  treatment  is  employed.  But 
tuberculin  treatment  is  not  merely  directed  against  a  few  glands 
in  one  area,  which  are  manifestly  tuberculous,  but  against  all  in- 
fected glands,  or  other  tuberculous  foci,  in  the  body,  and  when 
favorable  result  has  been  obtained,  the  possibility  of  a  further 
extension  of  the  disease  has  been  largely  removed.  But  since 
surgical  measures  do  not,  in  any  way,  prevent  recurrence  but 
expose  the  patient  to  the  advent  of  tuberculosis  elsewhere,  and 
since  the  knife  must  always  leave  a  certain  amount  of  mutilation, 
I  believe  these  measures  should  be  entirely  replaced  by  judiciously 
administered  tuberculin  therapy,  combined  with  general  hygienic 
and  dietetic  measures  and  other  useful  adjuncts  to  treatment, 
such  as  heliotherapy  and  the  X-ray,  when  they  are  available. 
In  addition,  we  should  clean  up  the  portals  of  entry  to  prevent 
added  infection. 

Results. — In  a  recent  article  DOWD  gives  the  following  results 
in  687  cases  treated  by  operation  by  himself,  or  his  associates 
and  assistants.  He  divides  his  cases  into  groups: 

Group  i . — In  this  group  he  classes  the  early  stages  of  infection 
with  involvement  of  the  upper  cervical  lymphatic  glands.  There 
were  452  patients  in  this  group.  Their  average  age  was  8.03 
years.  They  were  observed  for  variable  periods  of  time;  67  were 
followed  from  six  to  twenty  years;  23  were  followed  into  the  sixth 
year;  36  into  the  fifth  year;  53  into  the  fourth  year;  61  into  the 


PLATE  XIII. — Tuberculosis  of  the   cervical  glands  in  a   child.    Age  6.    Showing 
typical  results  following  tuberculin  treatment. 


TREATMENT  189 

third  year;  65  into  the  second  year  and  49  into  the  first  year;  98 
were  not  observed  after  leaving  the  hospital;  91%  of  the  cases 
traced  were  apparently  cured  when  last  seen;  9.75%  showed 
slight  evidence  of  recurrence;  i  patient  had  died  of  typhoid 
fever;  8%  had  secondary  operations  during  the  periods  of  ob- 
servation. 

Group  2. — In  this  group  are  included  cases  with  abscesses 
and  sinuses  and  involvement  of  glands  along  the  entire  jugular 
chain  and  the  anterior  border  of  the  Trapezius  muscle.  One 
hundred  and  eighty-five  patients  were  included  in  this  group, 
the  average  age  was  15.9  years,  and  69  were  over  20  years. 
Twenty-nine  of  these  patients  were  followed  from  six  to  twenty 
years;  n  were  followed  into  the  sixth  year;  18  into  the  fifth  year; 
14  into  the  fourth  year;  24  into  the  third  year;  19  into  the  second 
year  and  10  into  the  first  year;  60  were  not  observed  after  leaving 
the  hospital.  68.2  per  cent  of  the  patients  traced  were  ap- 
parently cured  when  last  seen;  23.8%  showed  recurrences  when 
last  seen;  5.5%  had  died  of  intercurrent  disease,  partly  tuber- 
culous; 2.4%  or  3  patients  died  in  the  hospital;  28.5%  of  the 
traced  patients  had  two  or  more  operations. 

Group  3. — This  group  included  those  with  diffuse  tuberculosis, 
the  patients  showing  little  resistance  to  tuberculosis,  the  neck 
infection  quickly  involving  a  great  number  of  nodes,  and  there 
were  usually  evidences  of  tuberculosis  elsewhere.  There  were  50 
patients  in  this  group,  and  their  average  age  was  12.7  years; 
13  of  these  patients  were  followed  from  six  to  seventeen  years; 
3  were  followed  into  the  sixth  year;  5  into  the  fifth  year;  2  into 
the  fourth  year;  5  into  the  third  year;  9  into  the  second  year, 
and  6  into  the  first  year;  34%  of  the  patients  traced  were  suffering 
from  recurrence  or  other  forms  of  tuberculosis;  20.4%  had  died  of 
intercurrent  disease,  largely  tuberculosis;  i  died  in  the  hospital 
after  a  minor  palliative  operation. 

These  statistics  may  be  taken  as  a  fair  average  of  the  results 
obtained  by  radical  operation. 

Currettement  of  the  glands  by  means  of  an  incision  and 
scraping  out  of  the  caseous  masses  is  inferior  to,  and  even  less 
to  be  advised,  than  is  excision  of  the  diseased  glands,  but  is 


igo     TUBERCULOSIS  OF  THE  LYMPHATIC   SYSTEM 

employed  by  some  in  advanced  cases  where  excision  is  im- 
possible. 

Suppurating  Glands  Should  be  Aspirated. — The  treatment  of 
suppurating  glands  should  be  instituted  early  before  they  rupture 
and  the  adjacent  tissues  become  involved.  The  indication  is 
to  remove  the  pus  in  the  simplest  possible  manner,  and  softened 
glands  may  be  treated  by  aspiration  or  incision.  I,  personally, 
employ  aspiration.  The  technique  is  simple.  The  skin  is  cleansed 
with  soap  and  water  and  alcohol,  or  tincture  of  iodine  applied. 
A  local  anesthetic  may  be  used  for  anesthetizing  the  skin,  if  it  is 
desired.  A  needle  should  be  selected  with  a  calibre  of  sufficient 
size  to  permit  the  withdrawal  of  pus,  which  is  often  thick  and 
curdy.  Aspiration  is  effected  by  means  of  a  syringe.  The  needle 
is  inserted  into  the  softened  gland  at  an  angle  and  through  the 
healthy  skin  and  subcutaneous  tissues,  rather  than  directly  over 
the  gland  at  a  point  where  rupture  is  threatening.  By  so  doing 
the  healthy  tissues  will  contract  and  the  needle  track  will  quickly 
heal  and  no  sinus  will  result,  as  might  be  the  case  if  the  needle 
were  inserted  at  the  point  of  threatened  rupture  where  the  skin 
is  thinned,  its  nutrition  impaired,  and  contraction  of  the  needle 
track  prevented  by  the  adhesions  to  the  underlying  tissues. 
One  aspiration  may  suffice,  or  it  may  be  necessary  to  repeat  it 
several  times,  inserting  the  needle  at  different  points  each  time. 
Under  tuberculin  the  glandular  enlargement  then  usually  sub- 
sides and  rupture  and  sinus  formation  is  prevented. 

Injections  into  the  Glands. — Injections  into  the  glands  have 
been  employed  by  many  from  time  to  time,  and  a  vast  number 
of  substances  have  been  employed  for  the  purpose.  Injections 
into  infiltrated  glands  are  not  to  be  advised.  After  removal  of 
the  pus  from  a  softened  gland  by  aspiration,  injections  into  the 
abscess  cavity  are  employed  by  some,  and  iodoform  in  oil  or 
glycerin  has  been  perhaps  the  most  extensively  used. 

An  incision  for  the  purpose  of  evacuating  the  pus,  contained 
in  a  softened  gland,  may  be  employed,  but  is  less  preferable 
than  aspiration.  Observing  the  usual  aseptic  precautions,  a 
small  incision  is  made  into  the  gland  and  the  pus  evacuated. 
The  lining  of  the  abscess  cavity  may  be  scraped  with  a  curette, 


TREATMENT  191 

and  the  wound  closed  by  sutures.  lodoform  emulsion  may,  or 
may  not,  be  injected  into  abscess  cavities  so  treated. 

Heliotherapy. — The  use  of  sunlight  as  a  therapeutic  agent 
in  the  treatment  of  various  maladies  dates  back  to  an  early  period 
of  time.  In  more  recent  years  solar  energy,  as  well  as  artificial 
light,  has  come  into  prominence  as  a  remedial  agent,  largely 
through  the  work  of  FINSEN.  In  addition  to  sunlight,  the 
Roentgen  ray  and  the  quartz  light  have  an  important  place  in 
treatment. 

Heliotherapy  in  the  treatment  of  tuberculosis  has  been  most 
extensively  employed  by  and  yielded  the  best  results  in  the 
hands  of  ROLLIER.  In  1903  he  established  at  Leysin,  Switzerland, 
a  sanitorium  for  the  exclusive  sunlight  treatment  of  surgical 
forms  of  tuberculosis.  Leysin  is  situated  in  the  Alps  at  a  height 
of  4,000  feet  above  the  sea  level.  The  climatic  conditions,  char- 
acterized by  intense  sunlight,  dry  atmosphere,  free  from  dust 
and  insects,  but  little  wind,  a  moderate  warmth  in  summer  and 
not  too  great  cold  in  winter,  admit  of  insolation  in  both  seasons 
with  uninterrupted  open  air  life.  The  buildings  are  protected  from 
winds,  and  the  beds  are  placed  on  the  balconies  in  the  sunshine. 

Method  of  Application. — The  treatment  is  begun  with  grad- 
ual exposures,  at  first  for  only  a  short  interval,  and  repeated 
several  times  a  day.  The  feet  are  first  exposed,  then  the  legs, 
thighs,  pelvis,  abdomen  and  thorax,  the  latter  being  reached  at 
the  end  of  about  seven  or  eight  days.  The  length  of  time  of  the 
exposures  and  their  frequency  are  gradually  increased  until  the 
entire  body  is  pigmented,  and  then  general  exposures  of  the  naked 
body  are  given.  The  eyes  are  protected  from  the  direct  rays  of 
the  sun  and  by  the  gradual  exposure  to  the  sun's  rays,  pigmenta- 
tion occurs  without  the  production  of  a  dermatitis  solarum,  or 
other  discomfort  to  the  patient.  The  intensity  of  the  sunlight 
in  the  higher  altitudes  is  much  greater  than  at  lower  levels, 
especially  during  the  winter  months.  There  is  a  marked  differ- 
ence in  the  sun  and  shade  temperatures.  When  there  is  snow  on 
the  ground  the  thermometer  may  register  o°  C.  in  the  shade  and 
50°  to  60°  in  the  sunshine. 

The  Ultraviolet  Rays. — The  volume  of  the  ultraviolet  rays 


iQ2     TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

of  the  sunlight  increases  with  the  higher  level  of  altitude.  The 
difference  in  the  intensity  of  these  rays  in  summer  and  winter 
is  comparatively  small  at  the  high  altitude,  but  is  great  at  a 
low  level. 

Theory  of  the  Action. — It  is  not  yet  possible  to  explain  the 
exact  nature  of  the  mechanism  of  the  reaction  of  the  tissues  to 
the  exposure  to  sunlight.  Both  the  invisible  and  the  visible  rays 
doubtless  perform  definite  therapeutic  functions.  The  visible 
rays  furnish  a  factor  of  warmth,  and  from  the  invisible  are  de- 
rived the  chemical  effects  of  the  actinic  or  ultraviolet  rays. 

Effects  of  Exposure. — Some  of  the  effects  of  the  exposure  to 
sunlight,  which  are  noted  clinically,  may  be  considered.  The 
first  effect  noted  is  a  hypertrophy  of  the  skin.  There  is  an  in- 
crease in  the  pigmentation  and  in  the  growth  of  hair.  Pigmenta- 
tion is  believed  to  play  an  important  role  in  the  treatment.  It 
is  believed  that  it  lowers  the  resistance  of  the  skin  to  the  passage 
of  the  light  rays  and  modifies  the  heat  rays  so  as  to  remove  their 
harmful  effects.  The  hypertrophy  increases  the  vitality  and 
resistance  of  the  skin,  affording  added  protection  from  the  cold. 
ROLLIER  regards  early  advent  of  pigmentation  as  prognostic  of 
good  results.  He  has  observed  that  the  rapidity  of  healing  of 
the  disease  is  proportionate  to  the  degree  of  pigmentation  and 
that  blondes  were  less  responsive  and  required  longer  treatment. 

More  recently  JESIONEK  44  has  stated,  that  he  considers  the 
pigment  to  be  the  main  factor  in  the  therapeutic  action  of  light 
as  applied  in  heliotherapy.  He  considers  that  the  effect  ob- 
served in  this  method  of  treatment  is  due,  not  to  the  pigment  re- 
tained in  the  cells,  but  to  the  excess  which  is  formed  and  thrown 
of!  by  the  cells.  He  assumes  that  certain  substances  are  formed 
as  products  of  the  special  activity  of  the  skin,  in  consequence  of 
the  action  of  light,  and  believes  that  the  excess  of  these  substances 
gets  into  the  circulation  and  reaches  the  tuberculous  focus. 

Rapid  Absorption  of  Pigment. — That  pigment  can  be  rapidly 
absorbed,  is  proven  by  the  whitening  of  tanned  skins  when  no 
longer  exposed  to  sunlight.  Negroes  removed  from  their  natural 
environment  no  longer  generate  pigment  in  abundance,  and 
JESIONEK  believes  that  the  system  may  feel  the  lack  of  this 


TREATMENT 


193 


pigment  to  which  the  cells  have  become  accustomed  and  asks  if 
this  might  not  be  one  of  the  possible  causes  for  the  susceptibility 
to  tuberculosis  of  the  negro  race  in  civilization.  He  states  that 
among  whites  individuals  of  a  pronounced  brunette  type,  and 
hence  with  a  greater  pigment-producing  power,  acquire  tuber- 
culosis less  frequently  than  blondes.  For  these  and  other  reasons 
he  ascribes  to  the  melanotic  pigment  of  the  skin  great  importance 
in  the  success  of  heliotherapy. 

Effect  on  Metabolism. — The  Metabolism  is  raised.  The  dry 
mountain  air  is  invigorating,  the  appetite  is  stimulated,  and  the 
activity  of  the  organs  of  the  body  is  increased.  Increased  met- 
abolism increases  the  bodily  resistance  to  infection  and  stim- 
ulates the  natural  healing  process,  which  are  essential  for  the 
cure  of  any  tuberculous  lesion. 

The  Hemoglobin  Index  is  raised,  and  the  number  of  erythro- 
cytes  is  increased.  It  is  a  familiar  observation  that  the  latter 
occurs  with  residence  at  a  high  altitude.  The  sunlight  has  a 
vasomotor  excitant  effect  upon  the  circulation  of  the  skin,  which 
reacts  on  the  internal  circulation. 

The  cool  dry  mountain  air  has  a  stimulant  effect  on  the 
nervous  system,  and  the  respirations  are  increased  in  depth. 
The  exposure  to  sunlight  produces  a  local  hyperemia  which  has 
a  desirable  effect  on  the  lesions,  increasing  their  blood  supply 
and  flooding  them  with  antibodies  and  leucocytes,  thus  favoring 
their  healing. 

Ultraviolet  rays  have  a  bactericidal  effect,  but  in  heliotherapy 
it  is  probably  a  negligible  factor.  On  dark  days  treatment  with 
the  X-ray  or  the  Cooper  Hewitt  light  is  substituted  by  ROLLIER. 

Effect  of  the  Treatment. — The  effect  of  the  treatment  cannot 
be  considered  as  a  local  one,  except  to  a  very  slight  degree. 
We  must  suppose  that  the  general  condition  of  the  body  is 
strengthened  through  stimulation  of  the  metabolism  and  that, 
as  a  consequence,  the  body  is  put  in  a  position  to  overcome  the 
disease  and  bring  about  healing.  The  benefit  of  the  high  altitude, 
the  stimulant  effect  of  the  cool  dry  air  and  the  effects  on  the 
blood,  all  probably  have  something  to  do  with  the  success  of  the 
treatment.45 


i94    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

Rollier's  Success. — ROLLIER  has  treated  all  kinds  of  tuber- 
culous gland  cases,  from  the  simple  uncomplicated  ones  to  the 
suppurating  type  of  the  fistulae,  a  complete  recovery  is  the  rule. 
In  cases  of  suppurating  glands  the  pus  formation  is  at  first  in- 
creased but  later  is  followed  by  drying  up  of  the  discharge  and 
healing  of  the  fistulae.  In  addition  to  the  exposure  to  the  sun 
and  dietetic  measures,  the  children  receive  cod  liver  oil.  An 
attempt  is  made  to  prevent  the  formation  of  sinuses,  abscesses 
are  aspirated  and  injected  with  iodoform  in  oil  or  glycerin. 
When  not  exposed  to  the  sun,  sinuses  are  covered  with  an  alcohol 
dressing  to  prevent  secondary  infection.  Six  months  to  two 
years  are  required  for  treatment  of  gland  cases.  In  cases  where 
sinuses  form,  the  scars  are,  as  a  rule,  less  disfiguring  than  in 
cases  treated  by  a  radical  operation.46  HIRSCH  47  quotes  the 
following  statistics  of  tuberculous  lymph-nodes: 

88  cases  — 

8 i  cured 
6  improved 
i  died 

The  Disadvantages. — There  are  many  disadvantages  to 
ROLLIER'S  sunlight  treatment,  which  prevent  its  general  adop- 
tion in  the  treatment  of  tuberculosis  of  the  lymphatic  glands. 
A  high  altitude  is  required  and  in  this  respect,  and  in  the  other 
essential  climatic  conditions  of  intense  sunlight,  dry  air  and  little 
wind,  only  certain  localities  are  available.  The  number  of 
patients  must  necessarily  be  limited  for  this  and  other  reasons. 
At  lower  levels  there  are  fewer  sunny  days,  and  the  volume  of 
the  ultraviolet  rays  is  less  and  is  more  variable.  The  greater 
humidity  of  the  air  absorbs  a  portion  of  the  actinic  rays. 

WEBB  48  has  carried  out  ROLLIER'S  method  of  treatment  for 
three  years  at  Colorado  Springs.  He  finds  it  to  be  of  much  ben- 
efit in  the  treatment  of  surgical  tuberculosis — bones,  joints  and 
glands,  but  is  not  as  optimistic  about  it  as  ROLLIER.  He  warns 
against  the  careless  employment  of  sun  baths  without  medical 
control,  as  harm  can  be  done  by  them. 

That  exclusive  sunlight  treatment  cannot  be  adopted  at  low 


TREATMENT  195 

levels  and  in  ordinary  climates,  where  the  weather  conditions 
are  uncertain  and  vary  from  one  extreme  to  another,  is  evident. 
The  value  of  sunlight,  however,  cannot  be  contested.  Animal 
experiments  have  shown  that  animals  exposed  to  light  were  more 
resistant  to  infection  than  those  kept  in  the  dark.  The  detri- 
mental effect  of  the  depressing  influence  of  living  in  dark  hab- 
itations, as  do  many  of  the  poor  in  our  large  cities,  is  a  well- 
known  fact.  We  may,  therefore,  urge  an  outdoor  life  to  those 
who  are  infected  with  tuberculosis,  and  in  fact  we  should  urge 
all  individuals  to  spend  as  much  time  as  possible  in  the  fresh  air 
and  sunshine  if  they  would  be  healthy. 

In  the  treatment  of  tuberculosis  of  the  lymphatic  glands,  we 
may  employ  more  intensive  applications  of  actinic  rays  than  are 
obtained  in  sunlight  alone,  by  the  use  of  the  Roentgen  rays  or 
the  ultraviolet  rays  obtained  from  an  arc,  quartz  or  mercury 
vapor  light. 

Ocean  and  Mountain  Climates. — The  temperature  of  ocean 
climates  varies  less  according  to  latitude  than  inland  climates. 
Sea  air  is  pure  and  free  from  dust  and  pathogenic  microorganisms. 
It  is  moist  and  equable,  its  evenness  being  characteristic.  These 
characters  give  to  the  ocean  climate  a  sedative  and  relaxing 
effect  upon  the  nervous  system.  As  sea  air  is  at  its  maximum 
density  the  volume  of  each  inspiration  contains  relatively  a 
larger  quantity  of  oxygen  and  leads  to  increased  depth  and 
slowing  of  the  respirations.  The  mucous  membranes  and  skin 
are  more  active,  and  the  sea  air  is  a  stimulant  to  nutrition  and 
metabolism.  The  appetite  is  increased,  the  digestion  stimulated, 
muscular  strength  is  augmented  and  the  red  blood-cells  and 
hemoglobin  and  body  weight  are  increased.  It  has  long  been 
recognized  that  tuberculous  gland  cases  do  well  at  the  seaside 
resorts,  and  an  ocean  climate  is  expressly  indicated  in  glandular 
tuberculosis  when  the  lungs  are  not  also  affected.  In  addition 
sea  baths  are  available  at  ocean  resorts.  Sea  bathing  was 
advised  and  its  value  recognized  in  glandular  tuberculosis  by 
the  older  physicians.  A  number  of  factors  contribute  to  the 
therapeutic  value  of  sea  baths.  Besides  the  stimulating  effect 
to  the  skin  exerted  by  the  salt  water,  the  cooler  temperature  acts 


i96    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM 

as  a  thermic  stimulus  and  increases  metabolism  as  is  visible  in  a 
keener  appetite  and  increased  weight. 

As  a  means  for  stimulating  metabolism  the  indications  for 
sea  bathing  are  the  same  as  those  for  sea  climate  and  air.  They 
are  excellent  for  the  fairly  robust  individuals,  who  are  able  to 
withstand  strong  impulses,  but  are  unsuitable  for  anaemic  weak 
patients  who  cannot  react  properly.  The  frequency  and  the 
duration  of  sea  baths  will  depend  upon  the  reactive  capacity 
of  the  individual.  When  sea  bathing  is  not  available  some  results 
may  be  obtained  from  salt  water  baths  at  home. 

Mountain  climates  are  likewise  of  value  in  the  treatment  of 
glandular  tuberculosis.  At  high  altitudes  the  air  is  pure  and  free 
from  organisms  and  of  less  density  than  at  lower  levels.  The 
air  is  cool  and  dry  and  the  sunshine  is  abundant.  The  cardiac 
and  respiratory  functions,  the  nervous  system,  and  general 
metabolism  are  stimulated  and  the  number  of  red  blood-cells 
increased.  For  more  robust  patients  the  climate  is  valuable  but 
if  patients  are  not  robust,  but  weak  and  anaemic,  the  stimulating 
effect  may  be  harmful. 

Soap  Treatment. — Friction  with  soft  or  green  soap  was, 
according  to  CORNET, 49  recommended  by  Kappesser  who  noted 
in  a  patient  that  the  use  of  soft  soap  in  the  treatment  of  scabies 
caused  glandular  swellings  in  the  neck  to  disappear.  Since  that 
time  it  has  been  advised  and  employed  by  many  observers. 

KULBS  50  states  that  this  therapy  has  shown  many  brilliant 
results  in  the  treatment  of  glandular  tuberculosis.  HOFFA  51 
in  1899  noticed  the  increased  appetite  and  general  well-being 
as  well  as  the  resorption  of  the  tuberculous  glands  incident  to 
this  form  of  treatment.  In  recent  times  Kousch  has  brought 
forth  the  soap  treatment  and  claims  it  to  be  very  good  in  treat- 
ing tuberculosis.  KULBS  rubs  a  tablespoonful  of  green  soap  into 
the  skin  of  the  extremities  and  trunk  every  six  days,  changing 
the  place  of  inundation  at  each  rubbing.  He  rubs  for  about  five 
minutes,  lets  the  skin  dry  for  three  to  five  minutes  and  then 
washes  it  off  with  lukewarm  water.  By  so  doing  he  does  not  see 
irritation  of  the  skin  or  eczema  following  the  treatment.  Others 
employ  a  different  technique,  some  applying  the  soap  more 


TREATMENT  197 

often,  every  day  or  every  other  day.  Some  allow  the  soap  to 
remain  for  a  quarter  to  a  half  hour,  others  apply  it  at  night, 
and  do  not  wash  it  off  until  morning.  More  energetic  methods 
are  applicable  in  case  of  adults  because  of  the  harder  skin. 

Modes  of  Action  not  Known. — The  exact  mode  of  action  of 
the  soap  treatment  for  tuberculous  lesions  is  not  clear.  Green 
soap  is  a  combination  of  potassium  and  various  fatty  acids. 
When  applied  to  the  skin  it  causes  a  softening  of  the  epidermis 
and  more  vigorous  application  leads  to  erythema  and  irritation 
of  the  skin.  The  location  of  the  tuberculous  process  does  not 
seem  to  be  of  consequence  in  deciding  the  site  of  application  of 
soap.  The  value  of  the  treatment  has  been  attested  to  by 
HAUSSMAN,  KLINGELHOEFFER,  SENATOR,  KOLLMAN,  CORNET 
and  others.52  This  treatment  is  simple  and  easily  employed 
anywhere  and  may  be  used  even  for  the  poorest,  and  if  it  is  of 
any  value  it  merits  some  consideration.  This  form  of  treatment 
would  seem  to  be  very  inadequate  in  view  of  the  now  recognized 
nature  of  the  enlargement  and  would  not  be  considered,  but  for 
the  reputation  of  the  investigators  reporting  success  in  its  use. 


BIBLIOGRAPHY 

CHAPTERS  I,  II  and  III 
ANATOMY  AND  PHYSIOLOGY 

1.  F.  R.  Sabin:  Am.  Journal  of  Anatomy.    IQCH-'OS,  4. 

2.  Delamere,  Poirier  and  Cuneo:  The  Lymphatics. 

3.  A.  Most:  Die  Topographi  des  Lymphgefassapparates  des  Kopfes 

und  des  Halses.    1906. 

4.  P.  Bartels:  Das  Lymphgef  assy  stem.    1909. 

5.  Henkle:  Arch.  f.  Laryngologie  und  Rhinologie.    1914,  Bd.  28,  Ht. 

2,  p.  231. 

6.  K.  Amersbach:  Arch.  f.  Laryngologie  und  Rhinologie.    1914,  Bd. 

29,  Ht.  i,  p.  29. 

7.  G.  B.  Wood:  Tonsillar  Infection.    Therap.  Gazette.     1915,  3rd 

s.  XXXI,  p.  83. 

8.  W.  S.  Miller:  The  Anatomical  Record.    Vol.  5,  No.  3.   The  Amer- 

ican Journal  of  Roentgenology,  1917,  June. 

9.  W.  S.  Miller:  Bulletin  of  the  Robert  Koch  Society  for  the  Study 

of  Tuberculosis,  1913-1916. 

10.  R.  Tigerstedt:  Lehrbuch  der  Physiol.  des  Menschen,  1913. 

11.  Carlson,  Grear  and  Becht:  Amer.  Journal  of  Phys.    Boston,  1908, 

22. 

12.  Carlson,  Grear  and  Luckhard:  Ibid. 

13.  Starling:  Principles  of  Human  Physiology,  1912. 

14.  Luciani:  Human  Physiology.    1911. 


CHAPTER  IV 
ETIOLOGY 

1.  Bandelier  and  Roepke:  A  Clinical  System  of  Tuberculosis. 

2.  Much,  H.:  Die  nach  Ziehl  nicht  darstellbaren  Formen  d.  Tb.  Bz. 

Berlin,  klin.  Wochenschr.    1988,  p.  691. 


200  BIBLIOGRAPHY 

3.  Quoted  from  Bandelier  and  Roepke:  A  Clinical  System  of  Tuber- 

culosis. 

4.  Quoted  from   Baldwin:   Etiology   of  Tuberculosis.     Osier  and 

McCrae. 

5.  Ibid. 

6.  Quoted  from  McFarland:  Text-book  upon  the  Pathogenic  Bac- 

teria. 

7.  Quoted  from  Baldwin:  Etiology  of  Tuberculosis.     Osier  and 

McCrae. 

8.  Chabas:  Deux  erreurs  de  la  phthisiologie:  La  predisposition  et 

1'heredite  Revue  internat.  de  la  tuberculose.     1914,  Vol. 

XXV,  p.  79- 

9.  Quoted  from  Baldwin:  Etiology  of  Tuberculosis.     Osier  and 

McCrae. 
10.  Theobald  Smith:  Transactions,  Assn.  Amer.  Phys.     1896,  XI, 

P-75- 
n.  G.  Cornet:  Scrofulosis,  2nd  Ed. 

12.  Duval:  Journal  of  Exper.  Med.  XI,  1909. 

13.  Quoting  from  Much,  H. :  Die  Immunitats-wissenschaft.    1914. 

14.  G.  Cornet:  Die  Tuberculose,  2nd.  Ed. 

15.  Park:  Congr.  of  Hyg.  and  Demography.    1912,  Wash.  Vol.  IV, 

267. 

16.  A.  P.  Mitchell:  The  Journal  of  State  Med.    1915,  XXIII,  p.  i. 

Journal  of  Path,  and  Bact.    1917,  XXI. 

17.  Woodhead:  Tr.  XV,  Internat.  Congr.  Hyg.  and  Demography. 

1912,  Wash.  Vol.  IV,  252 

18.  Copeland:  VT.  Int.  Congr.  on  Tuberculosis.    1908,  II,  379. 

19.  Quoting  from  Copeland:  Ibid. 

20.  Young:  Journal  of  State  Med.    1915,  XXIII,  21. 

21.  Quoting  from  G.  Thompson:  Medical  Press  and  Circular.    1913, 

95,  P-  33- 

22.  Baldwin:  Loc.  tit. 

23.  Quoted  from  Clopper:  Arch,  of  Ped.    1915,  XXXII,  843. 

24.  Manning  and  Knott:  Am.  Journal  of  Dis.  Child.    1915,  X,  354. 
Rosquist:  Finska  lakaresallskapets  forhandl.     1913,  LV  (i),  p. 

186. 

25.  Manning  and  Knott:  Loc.  cit. 

26.  Fishberg:  Arch,  of  Ped.    1915,  XXXH,  p.  20. 

27.  Manning  and  Knott:  Loc.  cit. 

28.  H.  Brown:  A.  Journal  Abst.    1913,  68. 


BIBLIOGRAPHY  201 

29.  Wollstein  and  Bartlett:  Am.  Journal  of  Dis.  of  Child.    1914,  8, 

p.  362. 

30.  Quoted  '.Ibid. 

31.  Rothe:  Deutsche  med.  Woch.    1911,  XXXVII,  I,  343. 

32.  J.  L.  Morse:  Boston  M.  and  S.  Journal.    1915,  CLXXIII,  p. 

655; 

33.  O.  Medin:  Arch.  f.  Kinderh.    1913,  61,  p.  482. 

34.  Quoted  from  Rothe:  Loc.  cit. 

35.  Rothe:  Loc.  cit. 

36.  Wollstein  and  Bartlett:  Loc.  cit. 

37.  Hedren:  Zeitschr.  f.  Hyg.  und  Infekt.    1913,  73,  p.  273. 

38.  Quoted  from  A.  Most:  Die  Topographic  des  Lymphgefassapp.  des 

mensch.  Korp.  etc.    Bibl.  med.  Abt.  C,  Heft,  21. 

39.  Cornet:  Scrofulosis,  2nd  Ed. 

40.  Quoted  from  K.  Hochsinger:  Kassowitz,  Festschrift.    1912.    G. 

Cornet:  Scrofulosis.    Engel:  Med.  Kl.  Berlin.    1913,  IX, 
2099. 

41.  Quoted  from  O.  Heubner:  Lehrbuch  der  Kinderheilkunde.     G. 

Cornet:  Scrofulosis. 

42.  O.  Heubner:  Lehrbuch  der  Kinderheilkunde. 

43.  B.  Salge:  Scrofula,  The  Diseases  of  Children.    Ed.  by  Pfaundler 

and  Schlossman. 

44.  K.  Hochsinger:  Was  ist  Scrofulose?   Kassowitz,  Festschrift.    1912. 

45.  Quoted  from  B.  Salge:  Loc.  cit. 

46.  E.  Smith:  Disease  in  Children. 

47.  Holt:  Diseases  in  Infancy  and  Childhood. 

48.  Baldwin:  Etiology  of  Tuberculosis.    Osier  and  McCrae. 


CHAPTER  V 
PATHOLOGY 

1.  Calmette:  Revue  de  la  tuberculose.    1913,  No.  5,  321. 

2.  Quoting  from  Calmette:  Ibid. 

3.  G.  Cornet:  Scrofulosis,  2nd  Ed.    1914. 

4.  F.  Harbitz:  Munch,  med.  Woch.    1913,  K,  p.  741. 

5.  Quoting  from  W.  H.  Park:  Arch,  of  Ped.    1915,  XXXII,  485. 

6.  G.  Cornet:  Scrofulosis,  2nd  Ed.  1914. 

7.  Quoting  from  Baldwin:  Et.  of  Tuberculosis.    Osier  and  McCrae. 


202  BIBLIOGRAPHY 

8.  Medin:  Loc.  cit. 

9.  Quoting  from  Bandelier  and  Roepke:  A  Clinical  System  of  Tuber- 

culosis, 2nd  Ed.    1913. 

10.  Zarfl:  Jahrb.  f.  Kinderh.    1913,  LXXVII,  p.  95. 

11.  Quoted  from  Stoll  and  Heublein:  Am.  Journal  of  M.  Sc.  Phil. 

1914,  148,  p.  369. 

12.  C.  Hedren:  Loc.  cit. 

13.  A.  Ghon:  Der  primare  Lungenherd  bei  der  Tub.  der  Kinder.    1912. 

14.  Quoting  from  Calmette:  Loc.  cit. 

15.  Wollstein  and  Bartlett:  Loc.  cit. 

16.  Calmette:  Revue  de  la  tuberculose.    1913,  No.  35,  321. 

17.  Quoting  from  Calmette:  ibid. 

18.  L.  Findley:  Br.  Journal  Ch.  Dis.    1913,  X,  502. 

19.  Walsham:  The  Channels  of  Infection  in  Tuberculosis. 

20.  v.  Pirquet:  Edinb.  M.  Journal.    1914,  13,  p.  220. 

21.  G.  Cornet:  Scrofulosis,  2nd  Ed.    1914. 

22.  Cobbet:  Br.  Journal  Ch.  Dis.    1911,  VIII,  415. 

23.  Quoting  from  Calmette:  Loc.  cit. 

24.  A.  Ghon:  Loc.  cit. 

25.  Quoting  from  G.  Cornet:  Loc.  cit. 

26.  Hedren:  Loc.  cit. 

27.  Quoted  from  Woodhead:  Tr.  XV,  Intern.  Cong.  Hyg.  &  Demogr. 

Wash.    1912,  IV,  252. 

28.  Rothe:  Deutsche  med.  Woch.    1911,  XXXVII,  I,  343. 

29.  Wollstein  and  Bartlett:  Loc.  cit. 

30.  W.  H.  Park:  Congr.  Hyg.  and  Demogr.  Wash.    1912,  IV,  267. 

31.  Quoted  from  Cornet:  Loc.  cit. 

32.  Mitchell:  The  Journal  of  State  Med.    1915,  XXIII,  p.  i. 

33.  Woodhead:  Loc.  cit. 

34.  Quoted  from  Cornet:  Loc.  cit. 

35.  Gardiner:  Lancet.    1915,  189,  p.  752. 

36.  Lockard:  Tuberculosis  of  the  Nose  and  Throat. 

37.  G.  B.  Wood:  Perm.  Med.  Journal,  June.    1912. 

38.  Quoted  from  G.  Cornet:  Loc.  cit. 

39.  Pybus:  Lancet.    1915,  188,  1009. 

40.  Street:  Journal  of   Ophth.  Otology  and  Laryngology.     1915, 

21,  141. 

41.  Quoted  from  Bandelier:  Beitrage  z  Klin,  der  Tub.    1906,  Bd.  6. 

42.  Gardiner:  Loc.  cit. 

43.  Quoted  from  Pybus:  Lancet.    1915,  188,  1009. 


BIBLIOGRAPHY  203 

44.  Quoted  from  G.  Cornet:  Scrofulosis,  2nd  Ed.    1914. 

45.  J.  Grober:  Klin.  Jahrbuch.    1905,  XIV. 

46.  Quoted  from  Pybus:  Loc.  cit. 

47.  Pybus:  Ibid. 

48.  Blumenfield:  Zeitschr.  f.  Laryng.  u.  Rhinol.,  etc.    Bd.  I,  Ht.  4. 

1908. 

49.  Quoted  from  Simon:  Beitr.  z.  Klin.  d.  Tub.    1911,  XIX,  417. 

50.  Ibid: 

51.  Calmette:  Loc.  cit. 

52.  Lockard:  Tuberculosis  of  the  Nose  and  Throat. 

53.  Walsham:  Loc.  cit. 

54.  Jousset:  Pediat.  prat.    1914,  XII,  208. 

55.  Medin:  Loc.  cit. 

56.  Blair:  Surg.  Gyn.  and  Obst.    1914,  XVIII,  470. 

57.  H.  Starck:  Munch,  med.  Woch.    1896,  XLIII,  145. 

58.  Quoted  from  Moorehead:  J.  A.  M.  A.    1910,  55-495. 

59.  Ibid: 

60.  Quoted  from  G.  Cornet:  Loc.  cit. 

61.  H.  Starck:  Loc.  cit. 

62.  Enler:  Therapeut.  Monatshefte,  Berlin.    1915,  XXIX,  Sept. 

63.  Cook:  Dental  Review.    1899,  XIII,  97. 

64.  Moorehead:  J.  A.  M.  A.    1910,  55,  495. 

65.  A.  Moeller:  Munch,  med.  Wochensch.    1910,  No.  2. 

66.  Wright:  Bost.  Med.  and  Surg.  Journal.    1915,  172,  p.  8. 

67.  G.  Cornet:  Scrofulosis,  2nd  Ed.    1914. 
Calmette:  Loc.  cit. 

68.  Bandelier  and  Roepke:  A  Clinical  System  of  Tuberculosis. 

69.  Fordyce  and  Carmichael:  Lancet,  London.    1914, 1,  25-26. 

70.  Bandelier  and  Roepke:  Loc.  cit. 

71.  Scheltema:  Jahrb.  f.  Kinderh.    1914,  LXXX,  118. 

72.  Chancellor:  Zeitsch.  f.  Kinderh.  (orig.).    1914,  X,  p.  12. 

73.  Jousset:  Pediat.  prat.    1914,  XII,  208. 

74.  A.  Most:  Loc.  cit. 

75.  E.  Holt:  J.  A.  M.  A.    1913,  61,  p.  99. 

76.  Durck  and  Hektoen:  Handbook  of  General  Pathology. 

77.  Bartel:  Quoted  by  Cornet:  Scrofulosis,  2nd.  Ed. 

78.  Holt:  Diseases  of  Infancy  and  Childhood. 

79.  A.  J.  Mitchell:  Jour,  of  Path,  and  Bact.    1917,  XXI. 

80.  Eustace  Smith:  Chronic  Tuberculosis.     Practical  Treatise  on 

Diseases  of  Children. 


204  BIBLIOGRAPHY 

CHAPTER  VI 

SYMPTOMS 

1.  Edwards:  Tuberculous  Adenitis,  Textbook  of  Medicine. 

2.  Quoted  by  Cornet:  NothnagePs  Encyclopedia  of  Practical  Med- 

icine, American  Edition. 

3.  See  Cunningham's  Anatomy,  1913,  p.  1012. 

4.  Northrup,  Quoted  by  Edwards:  Textbook  of  Medicine. 

5.  Wollstein:  Archives  of  Internal  Medicine,  1909,  III,  221. 

6.  Schick:  Weiner  klin.  Wchsch.    1910,  XXIII,  p.  153. 

7.  Stoll:  Am.  Journal  Dis.  Children.    1912,  IV,  342. 

8.  Warthin:  Osier  &  McCrae,  System  of  Medicine. 

9.  Eustace  Smith:  Practical  Treatise  on  Diseases  of  Children. 

10.  Petruschky:  Munch,  med.  Wchschr.    1903, 1,  364. 

11.  Riviere:  Brit.  Med.  Journal.     1914,  No.  280,  p.  462. 

12.  Bing:  Ugesk  f.  laeger.    1910,  LXXII,  p.  199. 

13.  Phillipi 


14.  Nagel 

15.  Kramer 


Quoted  by  Stoll:  Am.  Jour.  Dis.  Child.     1912,  IV, 
P-  333- 


16.  Phillipi 

17.  Smith:  Wasting  Diseases  of  Children.    London,  1899,  p.  309. 

18.  Cornet:  Scrofulosis,  p.  241. 

19.  Stoll:  Am.  Jour.  Dis.  Child.    1912,  IV,  p.  333. 

20.  D'Espine:  Bulletin  de  1'acad.  de  med.  Paris.    1907,  LVII,  67. 

21.  Frazier:  Old  Dominion  Jour.  Med.  &  Surg.    1915,  XXII,  p.  63. 

22.  Morse:  Boston  Med.  &  Surg.  Journal,  CLXXIII,  654. 

23.  Howell:  Am.  Jour.  Diseases  of  Children.    1915,  X,  90. 

24.  Fishberg:  Pulmonary  Tuberculosis,  p.  387. 

25.  Stoll:  Am.  Jour.  Diseases  of  Children.    1912,  IV,  333. 

26.  Wohlgemuth,  quoted  by  Cornet:  Nothnagel's  Encyclopedia 

Practical  Medicine. 

27.  Treves,  Quoted  by  Holt:  Diseases  of  Infancy  and  Childhood,  p. 

841. 

28.  Holt,  Quoted  by  Holt:  Diseases  of  Infancy  and  Childhood,  p.  844. 

29.  A.  P.  Mitchell:  Journal  of  Path,  and  Bact.    1917,  XXI. 

30.  Quoted  by  Cornet:  Nothnagel's  Encyclopedia  of  Practical  Med- 

icine, American  Edition. 

31.  Holt:  Pediatrics.    1913,  XXV,  p.  315. 


BIBLIOGRAPHY  205 


32.  Dowd:  Annals  of  Surgery.    1903. 

33.  Osier:  Principles  and  Practice  of  Medicine,  p.  176. 

34.  Lexer:  Text  Book  of  Surgery,  p.  411. 


CHAPTER  VII 
PROGNOSIS 

i.  Hutinel:  Le  pronostic  des  adenopathies  tub.  du  mediastin.  chez 
1'enfant  Revue  de  la  tuberculose,  Paris.    1914,  2  S,  XL 

CHAPTER  VIII 
DIAGNOSIS 

1.  Dunham  and  Wolman:  Johns  Hopkins  Hospital,  Bulletin.    1911, 

XXII,  p.  231. 

2.  Bandelier  and  Roepke:  Clinical  System  of  Tuberculosis. 

3.  Zieler,  Wolff-Eisner,  Bandler  &  Kribick,  Pick,  Daels,  Arondale  & 

Falk,  Quoted  by  Cornet:  Scrofulosis,  p.  253. 

4.  Veeder  and  Johnson:  Amer.  Jour.  Diseases  of  Children.     1915, 

IX,  p.  481. 

5.  Pottenger:  Tuberculin  in  Diagnosis  and  Treatment,  p.  35. 

6.  Tice:  111.  Med.  Journal.    1909,  N.  S.  16,  291. 

7.  Bandelier  and  Roepke:  Lehrb.  d.  spez.  Diagn.  und  Ther.  d.  tub. 


8.  Lowenstein  &  Kaufman:  Zeitschrift  f.  Tub.  Bd.  X,  Heft.  i. 

9.  Pottenger:  Tuberculin  in  Diagnosis  &  Treatment,  p.  27. 

10.  Bandelier  and  Roepke:  Lehrb.  d.  spez.  Diagn.  und  Therap.  d. 

Tub.    1915. 
n.  Sahli:  Tuberculin  Treatment,  pp.  145-6. 

12.  Sahli:  Tuberculin  Treatment,  p.  85. 

13.  Besredka  et  Jupiele:  Ann.  de  1'inst.  Pasteur,  Paris.    1913,  XXVII, 

1009. 

Besredka  et  Manquknine:  Compt.  rend,  de  la  soc.  de  biol.  Paris. 
1914,  LXVI,  180-197. 

14.  Mclntosh  &  Fildes:  Lancet.    1914,  II,  485. 

15.  Bronfenbrenner:  Arch.  int.  med.  XIV,  p.  786. 


206  BIBLIOGRAPHY 

16.  Craig:  Amer.  Jour.  Med.  Sc.    1915,  150,  II,  p.  781. 

17.  Kinghorn  &  Twitchell:  Amer.  Jour.  Med.  Science.     1909,  N.  S. 

Vol.  137,  p.  404. 


CHAPTER  IX 

TREATMENT 

1.  A.  F.  Hess:  J.  A.  M.  A.    1914,  LXIII,  2176. 

2.  M.  E.  Lapham:  N.  Y.  Med.  Journal.    1915,  101,  p.  108. 

3.  Sahli's  Tuberculin  treatment.    Dr.  H.  Sahli.    1912. 

4.  Tuberculin  Therapy.    F.  M.  Pottenger,  Med.  Recorder,  Feb.  20, 


5.  Pottenger:  Ibid. 

6.  Quoted  from  Bandelier  and  Roepke:  A  Clinical  System  of  Tuber- 

culosis. 

7.  Quoted  from  H.  Much:  Die  Immunitatswissenschaft.    1914. 

8.  Bullock:  Br.  Journal  of  Tub.    1915,  IX,  126. 

9.  Quoted  from  Kolmer:  Infection,  Immunity  and  Spec.  Therapy. 

10.  Quoted  from  Sahli's  Tuberculin  Treatment. 

11.  Quoted  from  Bushnell:  Military  Surgeon.    1913,  XXXII,  29. 

12.  Bullock:  Loc.  cit. 

13.  H.  Much:  Die  Immunitatswissenschaft.    1914. 
14-  F.  C.  Smith:  J.  A.  M.  A.    1916,  LXVI,  77. 

15.  Wasserman  and  Bruck:  Quoted  from  Sahli's  Tuberculin  Treat- 

ment. 

16.  Sahli's  Tuberculin  Treatment,  p.  131. 

17.  Cornet:  Scrofulosis,  p.  250. 

18.  Wolff-Eisner:  Zentralblatt  fr  Bakteriologie,  XXXVII,  S.  3~455- 

Berl.  klin.  Woch.    1904,  Nos.  42-44  (quoted  by  Sahli). 
19. 

Recent  Advances  in  Knowledge  of  Allergic  Phenomena.    Ed- 


20. 
21. 


itorial  J.  A.  M.  A.    1915,  LXV,  p.  2240. 


22. 

23.  Bandelier  and  Roepke:  Lehrbuch  der  spez.  Diagn.  u.  Therap.  der 

Tub.    1915. 

24.  Quoted  from  Bandelier  and  Roepke:  Wilms,  Deut.  med.  Wochen- 

schr.    1911,  No.  36. 

25.  Dautwis:  Beiheft  z.  med.  Klin.    1908,  Ht.  9. 


BIBLIOGRAPHY  207 

26.  Hamman  and  Wollman:  Tuberculin  in  Diagnosis  and  Treatment. 
Ager:  Am.  Journal  Obst.    1911,  LXIII,  368. 

Stoll:  Am.  Journal  Med.  Science.    1911,  CXLI,  83. 

Philip:  Lancet.    1909,  II,  19. 

Griswold:  Northwest  Med.    1911,  III,  189. 

27.  Pirie:  Proceedings  .Royal  Society  Medicine.     1909-10,  Vol.  II, 

Part  i,  Electrotherapeutic  Section. 

28.  Broca  &  Mahar:  Strahlentherapie.    1914,  4. 

29.  Kienboeck:  Quoted  by  Skinner. 

Pirie:  Interstate  Med.  Journal.    1914,  XXI,  483. 

30.  Kienboeck:  Roentgen-Taschenbuch.    1911,  Bd.  Ill,  96. 

31.  H.  Mowat:  British  Med.  Journal.    1914,  II,  p.  n. 

32.  O.  H.  Petersen:  Strahlentherapie.    1914,  IV,  272. 

33.  Tixier:  Strahlentherapie.    1914,  IV,  272. 

34.  Tonsey:  Treatment  of  Tuberculous  Glands  of  Neck.    Medical 

Electricity  &  X-ray,  p.  1080. 

35.  Iselin:  Quoted  by  Petersen,  Therapie  der  Gegenwart.    1914,  LV, 

145- 

36.  Philipowiez:  Wien.  klin.  Woch.    1913,  XXVI,  2106. 

37.  Iselin:  Deutsch,  Zeitschr  f.  Chir.    Vol.  103,  p.  483. 

38.  Roques:  Arch,  d'electric  med.  Vol.  21,  No.  333,  p.  57. 

39.  O.  H.  Petersen:  Die  Therapie  der  Gegenwart.    1914,  LV,  145. 

40.  Fritsch:  Munch,  med.  Woch.    1913,  LX,  2610. 

41.  Blaisch:  Ergebn  der  Chir.  und  Orthop.    1913,  VII,  in. 

42.  von  Mutsenbacher:  Quoted  by  Johnson's  Therapeusis,  Vol.  Ill, 

385- 

43.  Bergonie:  Compt.  rend.  Acad.  des  sciences,  Paris.    1905,  140,  889. 

44.  Jesionek:  Zeitschrift  f.  Tuberk.    1915,  XXIV,  No.  6. 

45.  O.  H.  Petersen:  Therapie  der  Gegenwart.    1914,  LV,  145. 

46.  Dietrich:  Journal  American  Medical  Assn.  LXI,  2229. 

47.  Hirscb:  American  Journal  Obstetrics.    1913,  V.  68,  p.  370. 

48.  G.  B.  Webb:  Journal  of  Outdoor  Life.    1915,  XII,  No.  9,  277. 

49.  Cornet:  Scrofulosis,  p.  385. 

50.  Kiilbs:  Therapeutische  Monatshefte,    1914,  28,  661. 

51.  Hoffa,  quoted  by  Kulbs:  Ibid. 

52.  Haussman,  Klingelhoeffer,  Senator,  Kollman:  Quoted  by  Cornet: 

Scrofulosis,  p.  386. 


INDEX 


Acid-fast  bacilli,  30 

Actinomycosis  differentiated  from  tu- 
berculosis, 116 
Afferent  lymphatics,  5 
Age,  factor  in  etiology  of  tuberculosis, 

43 

Agglutination  test  in  tuberculosis,  143 
Air   passages,   upper,   infections   of   a 

factor  in  etiology  of  tuberculosis,  40 
American    ideas    on    tuberculosis    and 

scrofulosis,  55 
Amyloid   degeneration   in   tuberculous 

adenitis,  84 
Anaphylaxis,  162 
Ano-rectal  glands,  18 
Antibrachial  glands,  19 
Appendicular  glands,  17 
Auricular  glands,  6 

Auscultation  in  tuberculosis  of  bron- 
chial glands,  92 
Axillary  glands,  19 

infection  of,  77 

tuberculosis  of,  102 
diagnosis  of,  117 

Bacillus  tuberculosis,  see  Tubercle  bacil- 
lus 

avium,  30 

bovis,  29 

humanus,  25,  and  see  Tubercle  bacillus 

piscium,  30 

Bacteriology  of  tuberculosis,  25 
v.  Baumgarten's  views  on  congenital 

transmission  of  tuberculosis,  60 
Beraneck's  tuberculin,  155 
Bibliography,  199 
Brachial  glands,  19 
Bronchial  glands,  15,  86 

tuberculosis  of,  86 
auscultation  in,  92 
changes  in,  82, 114 


Bronchial  glands,  tuberculosis  of,  clini- 
cal diagnosis,  109 

complications,  95 

course  of  disease,  94 

cough  in,  no 

d'Espine's  sign  in,  in 

diagnosis  of,  109 

dyspnea  in,  no 

early  changes  in,  1 14 

gastra-intestinal  disturbances  in,  87 

hilus  shadow  in,  113 

importance  of  history  in,  109 

infection  may  be  primary  in,  61 

insidious  onset,  no 

inspection  in,  89 

lung  markings  in,  113 

Neisser's  pressure  method  in,  in 

nervous  manifestations  in,  87 

palpation  in,  90 

percussion  in,  91 

physical  signs  in,  89 

pressure  symptoms  in,  88 

prognosis  of,  106 

radiograms  in,  113 

spinal  dulness  in,  in 

spinalgia  in,  no 

stereoscopic  plates  in,  112 

symptoms,  general,  87 

temperature  changes  in,  88,  no 

tracheo-bronchoscopy  in,  112 

X-ray  in  diagnosis  of,  112,  114 
Bronchopulmonary  glands,  16 

Caecal  glands,  16 

Calcification  of  glands,  82 

Calmette's  views  on  nasal  infection,  71 

Caseation,  80 

Cervical  adenitis,  and  carious  teeth,  73 

Cervical  glands,  7,  8,  9 

as  portal  of  infection,  67 

changes  in,  82 


210 


INDEX 


Cervical  glands,  relation  to  tonsils,  68 
tuberculosis  of,  95 
carious  teeth  and,  73 
changes  in  glands  in,  82 
clinical  diagnosis  of,  115 
development  slow  and  painless,  96 
diagnosis  of,  115 

differential  diagnosis  of,  115,  116 
order  of  involvement,  95 
prognosis  of,  98,  107 
secondary  infection  in,  97 
sinuses  in,  97 
suppuration  in,  96 
Children,  autopsy  findings  in,  46 
born  free  from  tuberculosis,  43 
frequency  of  tuberculosis  in,  43,  and 

see  Infancy 

location  of  infection  in,  47 
r61e  of  lymph-glands  in  infection  of,  78 
susceptibility  of,  to  tuberculosis,  47 
Cleanliness,  in  prevention  of  tubercu- 
losis, 148 

Climate,  factor  in  etiology  of  tuber- 
culosis, 41 

Climatic  treatment  of  glandular  tuber- 
culosis, 195 
Coeliac  glands,  1 7 

Complement  fixation  test  in  tubercu- 
losis, 142 

Craig's  polyvalent  antigen,  143 
value  of  different  antigens,  142 
Complications  of  tuberculosis  of  bron- 
chial glands,  95 

Conjunctival  tuberculin  test,  128 
Cornet's    experiments    in    nasal    and 

pharyngeal  infection,  72 
views  on  tuberculosis  and  scrofulosis, 

So 
Cough,    in    tuberculosis    of    bronchial 

glands,  no 

Craig's  polyvalent  antigen,  143 
Cubital  glands,  19 
tuberculosis  of,  102 
diagnosis  of,  118 
Cutaneous  tuberculin  test,  119,  and  see 

v.  Pirquei's  test 

Cysts  differentiated  from  tuberculosis 
of  cervical  glands,  116 


Czerny's  theory  on  tuberculosis  and 
scrofulosis,  53 

Dental  defects  as  factor  in  etiology  of 

tuberculosis,  40 
d'Espine's  sign,  93,  in 
Diagnosis  of  glandular  tuberculosis,  109 
Dietetic  treatment  of  tuberculosis,  152 
Digestive    disturbances    as    factor    in 

etiology  of  tuberculosis,  39 
Dyspnea  in  tuberculosis  of  bronchial 

glands,  no 

Ear  as  portal  of  infection,  75 

Environment  as  factor  in  etiology  of 
tuberculosis,  41 

Escherich's  views  on  tuberculosis  and 
scrofulosis,  52 

Examination  of  school  children  in  pre- 
vention of  tuberculosis,  149 

Excision  of  tuberculous  glands,  182 
serious  in  children,  183 

Eye  as  portal  of  infection,  75 

Facies,  tuberculous,  90 

Factory  as  factor  in  etiology  of  tuber- 
culosis, 43 

Findley's  experiments  on  intestinal  in- 
fection, 64 

Fistulae  do  not  yield  to  X-ray  therapy, 
181 

Fresh  air  in  prevention  of  tuberculosis, 
148 

Gastric  glands,  17 

Gastro-intestinal  disturbances  in  tuber- 
culosis of  bronchial  glands,  87 
Giant-cell  formation,  79 
Gland  of  Rosenmuller,  20 
Glandular  infection,  prevention  of,  150 
tuberculosis,    see    Bronchial    glands, 
Cervical  glands,  Mesenteric  glands, 
Tttberculosis 

Head  and  neck,  glands  of,  6 

lymphatic  drainage  of,  10 
Heliotherapy  in  glandular  tuberculosis, 
191 

absorption  of  pigment,  192 


INDEX 


211 


Heliotherapy  in  glandular  tuberculosis, 

disadvantages  of,  194 

effect  of,  193 

effect  of  exposure,  192 

effect  on  metabolism,  193 

method  of  application,  191 

Rollier's  success  with,  194 

theory  of  action,  192 

ultraviolet  rays,  191 
Hemorrhoidal  glands,  18 
Hepatic  glands,  17 
Heubner's  views  on  tuberculosis  and 

scrofulosis,  53 

Hilus  shadow  in  tuberculosis  of  bron- 
chial glands,  113 
History,  importance  of,  in  diagnosis  of 

tuberculosis  of  bronchial  glands,  109 
Hochsinger's     views     on     tuberculosis 

and  scrofulosis,  54 

Hodgkin's  disease,  cervical  glands  en- 
larged in,  116 

differentiated  from  generalized  tuber- 
culous adenitis,  100' 
Holt's  views  on  tuberculosis  and  scrofu- 
losis, 55 
Home,  factor  in  etiology  of  tuberculosis, 

42 
Hypogastric  glands,  18 

Iliac  glands,  19 

Immunity  to  tuberculosis,  156 

Infancy,  tuberculosis  severe  in,  45,  and 

see  Children 
Infectious  diseases  as  factor  in  etiology 

of  tuberculosis,  38 
Infra-auricular  glands,  6 
Infra-clavicular  glands,  20 
Inguinal  glands,  20 

infection  of,  77 

tuberculosis  of,  102 

diagnosis,  118 
Inspection,  in  tuberculosis  of  bronchial 

glands,  89 

Intestinal  absorption,  mechanism  of,  62 
Intestinal  infection,  62,  63,  65 

bovine  evidence  of,  66 

Findley's  experiments  on,  64 

frequency  of,  65 


Intestinal  infection,  objection  to  theory, 
64,  65 

secondary,  67 

Walsham's  views  on,  64 
Intestinal  mucosa,  permeability  of,  63 
Intracutaneous  tuberculin  test,  127 

Koch's  new  tuberculin,  155 
old  tuberculin,  155 
phenomenon,  157 

Lacteal  vessels,  function  of,  23 
Lockard's  views  on  nasal  infection,  72 
Lumbar  glands,  1 7 
Lung,  lymphoid  tissue  of,  14 

markings,  in  tuberculosis  of  bronchial 

glands,  113 
Luschka's  tonsil,  14,  and  see  Pharyngeal 

tonsil 
Lymph,  circulation  of,  22 

composition  of,  21 

formation  of,  22 

microscopical  examination  of,  21 
Lymphangitis,  tuberculous,  84,  103 
Lymphatic  capillaries,  i 
Lymphatic  drainage,  of  accessory  sin- 
uses of  nose,  10 

of  ear,  10 

of  eye,  10 

of  gums,  10 

of  head  and  neck,  10 

of  larynx,  12 

of  nasal  cavity,  10 

of  oral  cavity,  1 1 

of  skin  of  head  and  neck,  10 

of  teeth,  ii 

of  throat,  1 1 
Lymphatic  duct,  right,  2 
Lymphatic  glands,  act  as  filter,  63,  78 

anatomy  of,  3,  6 

blood  supply  of,  5 

frequency  of  involvement  in  tuber- 
culosis, 101 

function  of,  23 

generalized  tuberculosis  of,  103 

nerve  supply  of,  5 

of  abdomen,  16 

of  head  and  neck,  6 


212 


INDEX 


Lymphatic  glands,  of  lower  extremities, 

2C 

of  pelvis,  1 8 

of  thorax,  14,  15 

of  upper  extremities,  19 

r6le  of,  in  tuberculous  infection  in 

children,  78 

tuberculosis  of,  see  Bronchial  glands, 
Cervical  glands,  Mesenteric  glands, 
Tuberculosis 
Lymphatic   leukemia,    cervical   glands 

enlarged  in,  116 

Lymphatic  system,  anatomy  of,  i 
compared   with   blood-vascular   sys- 
tem, i 

development  of,  i 
Lymphatic     trunks,     broncho-medias- 

tinal,  2 
jugular,  2 
subclavian,  2 
terminal,  2 
Lymphatic  vessels,  function  of,  23 

structure  of,  2 
Lymphatics,  afferent,  5 
Lymphoid  tissue,  3 

Malignant  tumors  differentiated  from 

tuberculosis  of  cervical  glands,  116 
Mammary  glands,  infection  of,  77 
Mastoid  as  portal  of  infection,  75 
Mastoid  glands,  6 
Meat,  a  source  of  infection,  36 
Mediastinal  glands,  15 
Mesenteric  glands,  16 
tuberculosis  of,  98 

changes  in,  83 

diagnosis  of,  117 

impaired  metabolism  in,  ico 

local     manifestations      in,      100, 
101 

often  no  characteristic  symptoms, 

99 

prognosis  of,  107 
simulating  appendicitis,  100 
usually  secondary,  09 
Mesocolic  glands,  16 
Metcalf's   views   on    tuberculosis   and 
scrofulosis,  56 


Milk,  selection  of,  in  prevention  of  tu- 
berculosis, 147 

source  of  infection,  35 
Modes  of  infection  of  tuberculosis,  58 

aerogenous,  60 

bronchogenous,  60 

by  external  lymphatics,  67 

congenital,  58,  59 

enterogenous,  62 

through  ovum,  58 

through  placenta,  59 

through  semen,  58 

Moorehead's  findings  in  dental  infec- 
tion, 74 

Moro's  ointment  test,  125 
Mountain    climate    in    treatment    of 

glandular  tuberculosis,  195 
Mouth  as  portal  of  infection,  71,  72 
Much's  granules,  significance  of,  31 

Neisser's  pressure  method  in  diagnosis 

of  tuberculosis  of  bronchial  glands, 

in 
Nervous  symptoms  in  tuberculosis  of 

bronchial  glands,  87 
Nervous  system,  instability  of,  factor 

in  etiology  of  tuberculosis,  39 
Nose  as  portal  of  infection,  71 

Occipital  glands,  6 

Ocean  climate  in  treatment  of  glandular 

tuberculosis,  195 
Odenthal's  findings  in  dental  infection, 

74 

Opsonic  index,  effect  of  X-rays  on,  175 
Outside  infection,  protection  from,  in 

prevention  of  tuberculosis,  149 
Overfeeding,  dangers  of,  153 

Palpation  in  tuberculosis  of  bronchial 
glands,  oo 

Pancreatico-splenic  glands,  17 

Para-uterine  glands,  18 

Parotid  lymph  glands,  7 

Pectoral  glands,  19 

Pediculosis  and  infection  with  tuber- 
culosis, 76 

Pedley's  views  on  dental  infection,  41 


INDEX 


213 


Percussion  in  tuberculosis  of  bronchial 
glands,  91 

Percutaneous  tuberculin  test,  125 

Pharyngeal  tonsil  as  portal  of  infection, 
70 

Pharynx  as  portal  of  infection,  71,  72 

Physical  signs  in  tuberculosis  of  bron- 
chial glands,  89 

v.  Pirquet's  tuberculin  test,  119 
degree  of  reaction,  1*22 
frequency  of  infection,  121 
positive  reaction  in,  120 
Pottenger's  views  on,  123 
reaction  due  to  sensitiveness,  120 
value  in  adults,  121 
value  in  children,  122 

v.  Pirquet  and  Schick's  views  of  tuber- 
culin reaction,  161 

Popliteal  glands,  tuberculosis  of,  103 
diagnosis  of,  118 

Pottenger's  views  on  tuberculin  test, 
123 

Pre-auricular  glands,  6 

Pre-caecal  glands,  16 

Predisposition,  factor  in  etiology  of 
tuberculosis,  36 

Prelaryngeal  glands,  9 
infection  of,  77 

Pressure  symptoms  in  tuberculosis  of 
bronchial  glands,  88 

Pretracheal  glands,  9 

Previous  disease,  factor  in  etiology  of 
tuberculosis,  38 

Prognosis  of  tuberculosis  of  lymphatic 
system,  105 

Prophylaxis,  in  tuberculosis,  145 

Pseudoleukemia,  cervical  glands  en- 
larged in,  116 

Pulmonary  glands,  16 

Radiograms  in  tuberculosis  of  bronchial 
glands,  113 

Receptaculum  chyli,  3 

Resistance,  in  prevention  of  tubercu- 
losis, 147 

Respiratory  tract,  care  of,  in  prevention 
of  tuberculosis,  150 

Retro-auricular  glands,  6 


Retro-peritoneal  glands,  tuberculosis  of, 
98,  and  see  Mesenteric  glands 

Retro-pharyngeal  glands,  8 

Right  lymphatic  duct,  2 

Rollier's  method  of  heliotherapy,  191, 
194 

Rosenmuller,  gland  of,  20 

Sacral  glands,  18 

Sahli's  objection  to  Wassermann  and 

Bruck's  theory,  161 
Salge's  views  on  tuberculosis  and  scrofu- 

losis,  53 
Saltman's  views  on   tuberculosis  and 

scrofulosis,  54 

Scalp,  portal  of  infection,  76 
Scheltema's  case  of  infection  through 

the  skin,  76 
School    children,    examination    of,    in 

prevention  of  tuberculosis,  149 
Schools,  factor  in  etiology  of  tubercu- 
losis, 43 
Scrofula,     abdominal,     98,     and     see 

Mesenteric  glands,  tuberculosis  of 
Scrofulosis,  relation  to  tuberculosis,  49 

American  ideas  on,  55 
Signs  of  tuberculosis  of  bronchial  glands, 
89 

of  tuberculous  adenitis,  85 
Sinuses    in    tuberculosis    of    cervical 

glands,  97 

Skin  of  face,  as  portal  of  infection,  76 
Smith's  (Eustace)  sign,  93 

views  on  tuberculosis  and  scrofulosis, 

55 

Soap  treatment  of  glandular  tubercu- 
losis, 196 
mode  of  action,  197 

Social  conditions,  factor  in  etiology  of 
tuberculosis,  41 

Specific  treatment  of  tuberculosis,  153 

Spinal  dulness  in  tuberculosis  of  bron- 
chial glands,  in 

Spinalgia  in  tuberculosis  of  bronchial 
glands,  no 

Starck's  case  of  dental  infection,  74 

Stereoscopic  plates  in  tuberculosis  of 
bronchial  glands,  112 


2I4 


INDEX 


Subinguinal  glands,  20 
Submaxillary  lymph-glands,  7,  8 
Submental  glands,  8 
Subpectoral  glands,  19 
Subscapular  glands,  19 
Suppurating  glands,  aspiration  of,  190 

injection  into,  190 
Suppuration  in  tuberculosis  of  cervical 

glands,  96 

Supra-trochlear  glands,  19 
Surgical  treatment  of  glandular  tuber- 
culosis, 182 

aspiration  of  suppurating  glands,  190 

early  operation  advised,  186 

excision,  182 

serious  in  children,  183 

injection  into  suppurating  glands,  100 

results,  1 88 

value  of,  185,  1 86 

Symptoms  of  tuberculosis  of  bronchial 
glands,  87 

of  tuberculous  adenitis,  85 
Syphilis,  cervical  glands  enlarged  in, 

"5 

Tabes  mesenterica,  98,  and  see  Mesen- 

leric  glands,  tuberculosis  of 
Teeth,  as  portals  of  infection,  73 

carious,  and  cervical  adenitis,  73 

tubercle  bacilli  found  in,  74 
Temperature  changes  in  tuberculosis  of 

bronchial  glands,  88 
Thoracic  duct,  2 
Tonsillar  ring,  of  Waldeyer,  12 
Tonsils,  as  portals  of  infection,  67,  68,  70 

diseased,  a  menace,  68 
associated  with  cervical  glands,  68 
to  be  removed,  151 

faucial,  12 

frequency  of  tuberculosis  of,  68 

lingual,  14 

of  Luschka,  14 

palatine,  12 

pharyngeal,  14 

secondary  tuberculosis  of,  70 
Topography,  factor  in  etiology  of  tuber- 
culosis, 41 
Tracheo-bronchial  glands,  15 


Tracheo-bronchoscopy   in    tuberculosis 

of  bronchial  glands,  112 
Treatment   of   glandular   tuberculosis, 

145 

climatic,  195 

dietetic,  152 

general,  151 

heliotherapy,  191,  and  see  Heliother- 
apy 

prophylactic,  145 

soap, 196 

specific,  153 

surgical,  182,  and  see  Surgical  treat- 
ment 

tuberculin,  153,  and  see  Tuberculin  in 
treatment 

X-ray,  174,  and  see  X-ray  therapy 
Tubercle,  formation  of,  79 
Tubercle  bacillus,  bacteriology  of,  25, 
and  see  Tuberculin,  Tuberculosis 

change  of  type,  30,  31 

chemistry  of,  28 

cultural  characteristics  of,  26 

difference  between  human  and  bo- 
vine, 29 

effect  of  antiseptics  on,  28 
of  cold  on,  27 
of  gastric  juice  on,  28 
of  heat  on,  27 
of  light  on,  28 
of  moisture  on,  27 

morphology  of,  25 

phylogenesis,  30 

relation  between  human  and  bovine 
types,  32,  33,  34,  35 

staining  characteristics,  26 

varieties  of,  29 

water  as  a  harbinger  of,  28 
Tuberculin  in  treatment  of  tuberculosis, 

153 
action  of,  155 

general,  163 

local,  164 
Beraneck's,  155 
constituents  of,  155 
dosage,  an  individual  question,  167, 

171 
dose,  diluting  and  preparation  of,  171 


INDEX 


215 


Tuberculin,  indications  for  use  of,  164 

Koch's  new,  155 
old,  154 

leaves  no  scar,  187 

method  of  administration,  165 

site  of  injection,  166 

theory  of  reaction  to,  159 

time  for  injection,  167 

toxic  phenomena  indication  of  reac- 
tion, 165 

value  of,  169 

varieties  of,  154 
Tuberculin  tests,  119 

conjunctival,  128 
contraindications,  129 
dangers,  129 
evidence  of  reaction,  128 
method  of  employment,  128 
Wolff -Eisner's  views  of,  129 

cutaneous,  119 
degree  of  reaction  in,  122 
frequency  of  infection,  121 
positive  reaction  in,  120 
Pottenger's  views  on,  123 
reaction  due  to  sensitiveness,  120 
value  in  adults,  121 
value  in  children,  122 

interpretation  of,  140,  141 

intracutaneous,  127 
delicacy  of,  127 
local  manifestations,  127 

Moro's  ointment  test,  125 

percutaneous,  125 
ointment  test,  125 
positive  manifestation,  125 
test  uncertain,  126 

v.   Pirquet's   test,    119,   and   see   ». 
Pirquet 

subcutaneous,  130 
contraindications,  139 
dangers,  139 
dosage,  130,  133,  135 
examination  prior  to,  130 
importance  of  temperature,  131 
method  employed,  132 
reaction,     135,     136,     137,     138, 

140 
selection  of  tuberculin,  132 


Tuberculin  tests,  subcutaneous,  specifi- 
city of,  138 

technique,  131 

time  for  injection,  133 

value  of,  130 

value  of  experience  with,  141 
Tuberculosis,  and  see  Bronchial  glands, 

Cervical  glands,  Mesenteric  glands, 

Tuberculin 

agglutination  test  in,  143 
bacteriology  of,  25 
bibliography,  199 
bovine  type  of  infection,  29,  32 
clinical  diagnosis,  109 
complement  fixation  test  in,  142 
diagnosis  of,  109,  118 
differential  diagnosis,  115 
etiology  of,  25 

generalized,  of  lymph-glands,  103 
glandular  involvement  in,  81,  and  see 

Bronchial  glands,  Cervical  glands, 

Mesenteric  glands 
immunity  to,  156 
in  children,  see  Children,  Infancy 
modes  of  infection,  58 
morbid  anatomy,  79 
pathogenesis,  58 
pathology,  58 
prognosis,  105 
prophylaxis,  145 
relation  of  scrofulosis  to,  49,  55 
signs  and  symptoms,  85 
specific  diagnosis,  118 
tonsillar,  frequency  of,  68 
treatment,     145,     and     see     Treat' 

ment 

Tuberculous  adenitis,  amyloid  degener- 
ation in,  84 
excision  in,  182,  183 
generalized,  103 
signs  and  symptoms,  85 
Tuberculous  facies,  90 
Tuberculous    infection,    versus    tuber- 
culous disease,  46 
Tuberculous    lymphadenitis,    due    to 

bovine  bacilli,  35 
lymphangitis,  84 


2l6 


INDEX 


Ultraviolet  rays,  in  glandular  tubercu- 
losis, 191 

Vaughn's  theory  of  tuberculin  reaction, 

162 

Vesicular  glands,  18 
Virchow's  views   on   tuberculosis   and 

scrofulosis,  52 

Waldeyer's  (tonsillar)  ring,  12 

first  line  of  defense,  67 
Walsham's  views  on  intestinal  infection, 

64 
Wassermann    and    Bruck's    theory    of 

tuberculin  reaction,  160 
Wolff-Eisner's    theory    of    tuberculin 
reaction,  161 

views  on  conjunctival  tuberculin  test, 

129 
Wright's  views  on  dental  infection,  75 


X-ray  in  diagnosis,  112,  114 
X-ray  therapy  in  glandular  tuberculosis, 
174 

dangers  of,  180 

dosage,  178,  179 

effects  of  exposure,  174 

effects  on  giant  cells,  175 

effects  on  opsonic  index,  175 

erythema  dose,  178 

fistulae  do  not  yield  to,  181 

healing  action  of,  176 

in  involvement  of  bronchial  glands, 
112,  115 

local  reaction,  180 

produces  definite  biologic  changes,  174 

protective  action  of,  177 

selective  action  of,  174 

technique,  177 

value  of,  176,  180 

views  of  investigators  on,  181 


Printed  in  the  United  States  of  America 


'HE  following  pages  contain  advertisements  of  a 
few  of  the  Macmillan  books  on  kindred  subjects. 


Tuberculosis  of  the  Bones 
and  Joints  in  Children 

BY  JOHN  FRASER,  M.D.,  F.R.C.S.E.,  Cn.M., 

Assistant  Surgeon,  Royal  Hospital  for  Sick  Children,  Edinburgh 

With  51  full  page  plates  (2  in  color)  and  164  figures  in  the  text. 

Royal  8vo,  352  pp.,  index,  $4.50 

Tuberculous  disease  of  the  bones  and  joints  is  in  large 
measure  a  disease  of  children,  and  as  a  result  of 
the  disastrous  consequences  which  so  often  follow  its 
course,  it  is  one  of  the  most  important  of  the  various 
forms  of  Tuberculosis.  This  work  deals  fully  with  the 
condition.  The  more  recent  investigations  on  the  Eti- 
ology are  fully  discussed,  the  Pathology  is  a  special  fea- 
ture, and  much  of  the  material  in  this  relation  is  original. 
Diagnosis,  Prognosis  and  Treatment  are  fully  discussed. 
Special  attention  has  been  paid  to  the  making  and  fitting 
of  the  various  splints. 

Dr.  Fraser  is  well  known  to  American  physicians 
through  his  various  magazine  contributions  and  lectures. 
His  book  is  without  doubt  one  of  the  most  important 
publications  that  has  yet  appeared  on  this  subject. 


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Infection  and  Resistance 

An  Exposition  of  the  Biological  Phenomena  underlying  the 
Occurrence  of  Infection  from  Infectious  Disease. 

BY  HANS  ZINSSER,  M.  D. 

Major,  Medical  Officers'  Reserve  Corps,  U.  S.  A.;  Professor  of 

Bacteriology  at  the  College  of  Physicians  and  Surgeons,  Co- 

lumbia University,  New  York 

With  a  Chapter  on  Colloids  and  Colloidal  Reactions 
BY  PROFESSOR  STEWART  W.  YOUNG,  Department  of  Chem- 

istry, Stanford  University 
New  Second  Edition,  completely  revised. 

Crmvn  8vo,  ill.,  bibliography,  index,  585  pp., 


Since  the  publication  of  the  first  edition  of  this  book,  four 
years  ago,  it  has  been  accepted  as  the  standard  work  on  the 
subject  in  our  language  and  has  been  termed  the  "classic 
on  Immunity  in  all  languages." 

The  book  has  been  rewritten  and  entirely  reset  and  all 
important  changes  necessitated  by  the  lapse  of  tune  have  been 
made,  also  much  new  material  has  been  added. 

The  chapters  on  An'aphylaxis  have  been  almost  completely 
rewritten.  The  Abderhalden  reaction  having  been  proved 
to  be  an  interesting  camouflage,  the  material  in  that  section 
has  been  revised  and  the  more  recent  work  on  Enzymes 
added.  The  development  of  conceptions  of  non-specific  serum 
and  cellular  reactions  has  been  discussed,  while  a  section  on 
Immunity  in  Syphilis  has  been  added  and  the  chapter  dealing 
with  specific  therapy  in  various  infections  has  been  revised 
and  expanded.  In  addition,  many  other  alterations  and  com- 
ments have  been  made. 


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The  Treatment  of  Acute  Infectious  Diseases 

BY  FRANK  SHERMAN  MEARA,  M.D. 

Professor  of  Therapeutics,  Cornell  Medical  School 


Cloth)  Svo, 


A  widely  known  teacher  has  written  this  book  along 
new  and  very  unusual  lines.  The  chapters  deal  with  in- 
dividual diseases  in  a  thoroughly  practical  manner,  each 
little  detail  of  procedure  being  explained  so  that  the 
reader  may  actually  apply  it.  The  reason  for  each  pro- 
cedure as  based  on  our  latest  information  is  given  with 
respect  to  both  physical  therapy  and  drugs. 

Of  especial  importance  is  the  Summary  at  the  end  of 
each  chapter,  where  the  most  important  points  of  the 
chapter  are  tabulated  for  the  use  of  the  student's  review 
and  for  the  busy  practitioner.  In  this  way  procedures 
that  necessarily  must  be  referred  to  again  and  again  will 
have  separate  consideration  and  will  be  referred  to  in 
the  individual  instances.  All  material  is  thus  imme- 
diately at  hand  without  constant  reference  to  other 
sources  or  other  parts  of  the  book.  The  work  is  unique 
in  its  conception  and  the  material  is  authoritative  in 
every  way. 


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Typhoid  Fever 

CONSIDERED  AS  A  PROBLEM  OF  SCIENTIFIC  MEDICINE 
BY  FREDERICK  P.  GAY 

Professor  of  Pathology  in  the  University  of  California 

Cloth,  8vo,  $2.50 

"In  this  book  the  author  undertakes  to  deal  with  typhoid 
fever  as  a  problem  of  scientific  medicine  rather  than  to  handle 
it  as  a  question  solely  of  the  clinic  or  of  the  laboratory.  The 
point  of  view  is  broad  and  the  treatment,  on  the  whole,  well 
balanced.  The  treatise  illustrates  one  of  the  newer  tendencies 
in  American  medicine,  and,  it  is  to  be  hoped,  will  prove  a 
forerunner  of  other  books  on  special  topics  which  shall  not 
only  give  critical  surveys  of  the  enormous  mass  of  accumu- 
lated research,  much  of  which  may  otherwise  remain  un- 
assimilated  and  valueless,  but  shall  also  stimulate  investiga- 
tion by  pointing  out  unsettled  questions.  .  .  . 

"As  might  be  anticipated  from  the  author's  own  work, 
the  chapters  on  immunization,  the  practical  aspects  of  vac- 
cination, and  vaccine  and  serum  treatments  are  particularly 
full  and  discriminating.  The  chapter  on  the  carrier  condition 
and  the  section  dealing  with  laboratory  diagnosis  of  typhoid 
are  also  informed  throughout  by  the  author's  own  personal 
experience.  .  .  .  The  book  has  a  good  bibliography." — 
Journal  of  American  Medical  Association. 

"The  author  has  presented  in  this  small  volume  an  ex- 
cellent exposition  of  the  problem  of  typhoid  fever.  ...  It 
treats  historically  the  development  and  present  status  of  our 
knowledge  concerning  this  important  malady  as  viewed  from 
the  standpoint  of  its  mechanism.  ...  It  shows  the  very 
close  relationship  between  the  clinical  and  the  laboratory 
side  of  the  disease  by  following  the  life  history  of  the  typhoid 
bacillus  rather  than  the  manifestations  of  the  disease  it 
produces.  .  .  .  The  chapter  on  the  protective  value  of 
vaccination  against  typhoid  fever  and  the  statistics  relative 
to  same  are  most  interesting  reading." — New  Orleans  Medical 
6*  Surgical  Journal. 

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